775 Montague Expressway

Mi Milpitas, CA 95035

Tel: 408-526-1188

Fax: 408-526-1088

Email:

Product Application Questionnaire

Company Name:

Company Address:

Company Contact: Name:

Telephone:

Fax:

Email:

Manufacturer Name:

Manufacturer Address:

Manufacturer Contact: Name:

Telephone:

Fax:

Email:

Factory Name:

Factory Address:

Factory Contact: Name:

Telephone:

Fax:

Email:

Local Representative Name:

Local Representative Address:

Local Representative Contact:

Telephone:

Fax:

Email:

When do you need this quote?

When will product be ready to start pre-testing? Complete pre-testing by

When will product be ready to start formal testing? Complete formal testing by

Requested Certifications:

Have Need

Applicable Standards: Safety:

EMC:

RF/Wireless:

Telecom:

PTCRB/CTIA/CCF Yes No PTCRB Request #:

Wi-Fi Alliance: Yes No Wi-Fi Alliance Request #:

GCF: Yes No GCF-CC Version:

Other: FCC IC CE Other Countries (see pages 6&7)

Telecom interfaces: Type: No# Type: No#

Equipment Under Test (EUT)

Brand Name: Model Number or Name:

Description (as it will appear in the test report and grant:

Configuration: Integrated Radio Module(s) Stand Alone Radio Module(s)

FCC ID: IC ID:

Radio Hardware Version: Radio Software Version:

Antenna Options: Yes No Diversity/MIMO Info:

Antenna: Single Multiple: How Many

Antenna Design: Internal External ≥ 20 cm < 20 cm

Radio Output Power:

Radio Modules Used: GSM WCDMA CDMA WLAN B/T Zigbee RFID NFC VoIP Other

Audio Support: Yes No

AGPS Mode Yes No : UE-Based UE-Assisted MS- Assisted

Variations to primary device Yes No :

Differences:

Body Proximity: Handheld Worn on body Held to ear Distance from Body

Explanation:

Power Supply: Internal , External , VAC , VDC

EMBEDDED RADIO MODULES

PTCRB Certification:

Module Manufacturer Model #

IMEI:

IMEI SV #:

Production Numbers: ≤ 10,000 > 10,000

Embedded SIM Socket Added SIM Socket

Power Interface Changes Yes No Explain:

Module Changes Yes No Explain:

Man-machine Interface Changes Yes No Explain:

GSM (2G/2.5G)

Module Make: Model:

FCC / IC ID:

Operating Frequency Bands: 850 900 1800 1900

Modulation Type: GMSK (GSM, GPRS) 8PSK (EGPRS)

Power Class: Multi-slot Power Class:

Antenna Type and Gain:

RF Connector Type: SMA UFL BNC N Other:

WCDMA / UMTS (3G)

Module Make: Model:

FCC / IC ID:

Operating Frequency Bands: FDD I FDD II FDD III FDD IV FDD V FDD VI FDD VII FDD VII FDD IX TDD

Power Class: Multi-slot Power Class:

Antenna Type and Gain:

RF Connector Type: SMA UFL BNC N Other:

CDMA

Module Make: Model:

FCC / IC ID:

Operating Frequency Bands: 800 1700 1900

Modulation Type: QPSK / HPSK (CDMA2000 HPSK (1xEV-DO

Power Class: Multi-slot Power Class:

Antenna Type and Gain:

RF Connector Type: SMA UFL BNC N Other:

LTE

Module Make: Model:

FCC / IC ID:

Operating Frequency Bands: TDD FDD

Power Class:

Resource Blocks:

Bandwidths supported:

RF Connector Type: SMA UFL BNC N Other:

WAN

Module Make: Model:

FCC / IC ID:

Operating Frequency Bands:

2.4GHz ISM / UNII-1 / UNII-2 / UNII-WW/DFS / UNII-3 / CH. 165
802.11a / 2450 / 5150-5250 / 5250-5350 / 5470-5725 / 5725-5850 / 5805-5845
802.11b / --
802.11g / -- / -- / -- / -- / --
802.11n / -- / -- / -- / -- / --
802.11h
DFS 20MHz 40 MHz

Antenna Type and Gain:

RF Connector Type: SMA UFL BNC N Other:

Bluetooth®

Module Make: Model:

FCC / IC ID:

Modulation Type: GFSK 8DPSK (EDR) π / 4 4.0 (LE)

Antenna Type and Gain:

RF Connector Type: SMA UFL BNC N Other:

Other Radios

Module Make: Model:

FCC / IC ID:

Operating Frequency Bands:

Modulation Type:

Power Class: Multi-slot Power Class:

Antenna Type and Gain:

RF Connector Type: SMA UFL BNC N Other:

Radio Co-location

Do any radios operate simultaneously: Yes No

If “Yes”, please indicate which ones:

Wi-Fi & BT Wi-Fi & GSM or WCDMA or CDMA

BT & FSM or WCDMA or CDMA Other:

Distance between antennas:

Product Certification Questionnaire

Does this product have CB Test Report? Yes No

If yes, CB Certificate No:

CB Issued Date:

CB Issued By:

Has the factory been inspected for producing this type of product(s)? Yes No

If yes, Factory Inspected by: Inspection Report No:

Factory Inspection Date:

Is this factory ISO 9000 or equivalently Certified? Yes No

If yes, ISO 9000 or equivalent standard’s version:

ISO 9000 or equivalently Certified by:

Please indicate which country or countries you’re applying for the Product Certification:

United States / Philippines
Canada / Sri Lanka
Austria / South Africa
Belgium / Latvia
Denmark / Poland
Finland / Lithuania
France / Hungary
Germany / Russia
Greece / Slovenia
Iceland / Bulgaria
Ireland / Estonia
Italy / Israel
Liechtenstein / Belarus
Luxembourg / Czech Republic


Product Certification Questionnaire

Norway / Morocco
Portugal / Slovak Republic
Spain / Ukraine
Sweden / Bahrain
Switzerland / Jordan
UK / Oman
Netherlands / Qatar
Croatia / Saudi Arabia
Japan / Kuwait
Australia / Egypt
New Zealand / UAE
India / Brazil
Hong Kong / Mexico
South Korea / Chile
Singapore / Colombia
Thailand / Venezuela
Taiwan / Argentina
PR China / Ecuador
Malaysia / Peru
Indonesia / Vietnam
Other
NOTE: Please attach a copy of your product’s brochure.

Thanks for your interest in SIEMIC Certification Services.

You will hear back from us of your inquiry within 24 hours.

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