IC Equipment Certification Application Form
Appendix A:Item 1.Applicant Information
Company Name:
Address:
Line 2:
City:
State:Country (if foreign address): Zip/Postal Code:
Contact Name:
Phone:Fax:
Email:
IC Company Number:
Item 2.Canadian Representative Information
Company Name:
Address:
Line 2:
City:
State:Country (if foreign address): Zip/Postal Code:
Contact Name:
Phone:Fax:
Email:
IC Company Number:
Item 3.Company Number:*UPN Number (11 characters maximum):
Model Number(s):
Specification Standard:
Type of Service: New SingleNew FamilyExisting FamilyMultiple ListingReassessment
Item 4. AGREEMENT:
THE APPLICANT AGREES TO:
(i) Accept responsibility for all charges arising from this application;
(ii) Meet all requirements in accordance with CB-03 and other applicable procedures;
(iii) Warrant that the test results submitted are a true representation of the characteristics of the radio equipment type for which certification is requested;
(iv) Inform Elite of any changes to the information submitted.
Name: Title:
Signature: Date:
Appendix B:
Manufacturer: / Applicant Company Number:
Model Number(s): / UPN Number:
Test Laboratory Name: / Product Name/Description:
IC OATS Registration #: / Antenna Type & Gain:
Emissions Information
Radio Standard / Frequency Range / RF Power / Bandwidth / Emission Classification / Transmitter Spurious
RSS No. / Issue No. / Minimum (MHz) / Maximum
(MHz) / Minimum (W) / Maximum (W) / Measured
(kHz) / Calculated
(kHz)
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
99%20dB26dBOther
Agreement Signature
DECLARATION OF COMPLIANCE: I declare that the testing was performed or supervised by me; that the test measurements were made in accordance with the above-mentioned Industry Canada standard(s); and that the equipment identified in this application has been subjected to all the applicable test conditions specified in the Industry Canada standards and all of the requirements of the standard have been met.
Applicant Name: / Applicant Title:
Applicant Signature: / Signature Date:
Annex A – RF Technical Brief Cover Sheet
All Fields must be completed with the requested information or the following codes: N/A for Not Applicable, N/P for Not Performed or N/V for Not Available. Where applicable, check appropriate box.
Company Number:
Model Number:
Manufacturer:
TYPE OF EVALUATION: Complete the applicable sections: (a) SAR Evaluation: Device Used in the Vicinity of the Human Head; (b) SAR Evaluation: Body-worn Device;(c) SAR Evaluation: Limb-worn Device (d) RF Evaluation)
Note: The worst-case scenario (i.e. highest measured value obtained) should be reported.
(a) SAR Evaluation: Device used in the Vicinity of the Human Head
● Multiple transmitters: Yes No
● Exposure limits used: General Public Use Controlled Use
● Duty cycle used in evaluation: %
● Standard used for evaluation:
● SAR value: W/kg. Measured Computed Calculated
(b) SAR Evaluation: Body-worn Device
● Multiple transmitters: Yes No
● Exposure limits used: General Public Use Controlled Use
● Duty cycle used in evaluation: %
● Standard used for evaluation:
● SAR value: W/kg. Measured Computed Calculated
(c) SAR Evaluation: Limb-worn Device
● Multiple transmitters: Yes No
● Exposure limits used: General Public Use Controlled Use
● Duty cycle used in evaluation: %
● Standard used for evaluation:
● SAR value: W/kg. Measured Computed Calculated
(d) RF Evaluation
● Exposure limits used: General Public Use Controlled Use
● Duty cycle used in evaluation: %
● Standard used for evaluation:
● Measurement distance: m
● RF value: V/m A/m W/m2
● Measurement Method: Measured Computed Calculated
Annex B - Declaration of RF Exposure Compliance
ATTESTATION: I attest that the information provided in Annex A is correct; that the TechnicalBrief was prepared and the information contained therein is correct; that the device evaluation wasperformed or supervised by me; that applicable measurement methods and evaluationmethodologies have been followed; and that the device meets the SAR and/or RF field strengthlimits of RSS-102.
Signature: Date:
NAME (Please print or type):
TITLE (Please print or type):
COMPANY (Please print or type):
Annex C - Declaration of RF Exposure Compliance for Exemption from Routine Evaluation Limits
ATTESTATION: I attest that the radiocommunication apparatus meets the exemption from theroutine evaluation limits in Section 2.5 of RSS-102; that the Technical Brief was prepared andthe information contained therein is correct; that the device evaluation was performed orsupervised by me; that applicable measurement methods and evaluation methodologies have beenfollowed; and that the device meets the SAR and/or RF field strength limits of RSS-102.
Signature: Date:
NAME (Please print or type):
TITLE (Please print or type):
COMPANY (Please print or type):
Modular Requirements
To obtain equipment certification for a modular device, the application for equipment certification shall include a cover letter in which the applicant requests modular approval for the transmitter concerned. The application for equipment certification shall also include the following completed checklist demonstrating that the modular transmitter complies with each of the following conditions:
Modular approval requirement / Yes/No*
The radio elements must have the radio frequency circuitrymust be shielded. Physical/discrete and tuning capacitors may belocated external to the shield, but must be on the module assembly.
The module shall have buffered modulation/data input(s) (if such inputs are provided) to ensure that the module will comply with the requirements set out in the applicable RSS standard under conditions of excessive data rates or over-modulation.
The module shall have its own power supply regulation on the module. This is to ensure that the module will comply with the requirements set out in the applicable standard regardless of the design of the power supplying circuitry in the host device which houses the module.
The module shall comply with the provisions for external power amplifiers and antennas detailed in this standard. Theequipment certification submission shall contain a detailed description of the configuration of all antennas that will be used with the module.
The module shall be tested for compliance with the applicable standard in a stand-alone configuration, i.e. the module must not be inside another device during testing.
The module shall comply with the Category I equipment labeling requirements.
The module shall comply with applicable RSS-102 exposure requirements, which are based on the intended use/configurations.
Is the modular device for an Industry Canada licensed exempt service?
* Please provide a detailed explanation if the answer is “No.”
Limited Modular Approval (LMA)
LMA may be granted when one or more of the requirements in the table above cannot be demonstrated.
LMA will also be issued in those instances where applicants can demonstrate that they will retaincontrol over the final installation of the device, such that compliance of the end product is assured. Insuch cases, an operating condition on the LMA for the module must state that the module is onlyapproved for use when installed in devices produced by a specific manufacturer.
When LMA is sought, the application for equipment certification must specifically state how control ofthe end product into which the module will be installed, and will be maintained, such that fullcompliance of the end product is always ensured.
Signature: Date:
Instructions for completing the Elite Electronic Engineering, Inc.
Industry CanadaEquipment Certification Application Form
AppendixA:
Item 1:Please complete these sections with the APPLICANT’S contact information. All correspondence regarding the application will be directed to this contact. When issued, the original certificate will be sent to this contact. This contact may not always be the test lab that performed the testing of the device. This contact may be a third-party agent or the Applicant itself. Please complete all areas.
Item 2:Please complete these sections with the CANADIAN REPRESENTATIVE’S contact information. The applicant must provide, in writing, the identity of a representative in Canada who is capable of respondingto enquiries and who can provide post-certification audit samples at no charge to Industry Canada.
Item 3:Certified radio equipment must be labeled with a unique certification/registration number, which consists of theCompany Number (CN), assigned by the Bureau, followed by the Unique Product Number (UPN), assignedby the TAC or Certificate holder.
The certification number is made up of a Company Number (CN) assigned by the Bureau followed by the Unique Product Number (UPN), assigned by the applicant.
The certification number shall appear as follows:“IC: XXXXXX-YYYYYYYYYYY”
Where:
• “XXXXXX-YYYYYYYYYYY” is the certification number;
• “XXXXXX” is the Company Number (CN) assigned by Industry Canada, made of at most 6 alphanumeric characters (A-Z, 0-9), including a letter at the end of the CN to distinguish between different company addresses;
General Requirements and Information for the
Certification of Radiocommunication Equipment RSS-Gen
12
• “YYYYYYYYYYY” is the Unique Product Number (UPN) assigned by the applicant, made of at most 11 alphanumeric characters (A-Z, 0-9); and
• the letters “IC” have no other meaning or purpose than to identify the Industry Canada certification number.
Permitted alphanumerical characters used in the CN and UPN are limited to capital letters (A-Z) and digits (0-9). An example of the new format for a company having a CN of “21A” and wishing to use a UPN of “WILAN3” would thus be: IC: 21A-WILAN3. Each equipment model shall be explicitly identified. The use of characters, such as #, / or -, in the certification number is not allowed. The use of "wild card" characters in the model number (for the purpose of identifying multiple models with one name) is not allowed.
Equipment that has received certification but is not labeled with the applicant’s name, model number and the certification number as outlined above is not considered certified.
Item 4:Please affix the signature and Title of the authorized Applicant.
AppendixB:
Please complete the appropriate sections for the Equipment Specifications.
Annex A, B, and C:
Please complete the appropriate sections for Annex A and B or C.To obtain approval under this Standard, the above mentioned application for certification shall beaccompanied by the duly completed RF technical brief cover sheet (see Annex A) and a properly signeddeclaration of compliance (see Annex B). However, if the device in question meets the exemption from routine evaluation limits of Sections 2.5.1 or 2.5.2 of RSS-102, only a properly signed declaration of compliance (Annex C)shall be submitted.Although submission of the RF exposure technical brief is not required for certification, it shall be madeavailable upon request, for as long as the device model is marketed in Canada.
Modular Approval Requirements:
To obtain equipment certification for a modular device, the application for equipment certification shallinclude a cover letter in which the applicant requests modular approval for the transmitter concerned.The application for equipment certification shall also include the included completedchecklistdemonstrating that the modular transmitter complies with each of the required conditions.FOR USE BY ELITE PERSONNEL ONLY DO NOT MARK BELOW LINE
Form Confirmation
Confirmation Number / Date filed w/ICDate / Rev. / Description
05/12/2006 / 1.2 / Re-format to match Appendix I and Appendix II of RSP-100.
10/10/2006 / 1.3 / Removed references to RSP-100 and reference to CB-03
04/02/2008 / 1.4 / Updated Labeling requirements
03/12/2009 / 1.5 / Added Annex A and B forms
05/04/2010 / 1.6 / Added Annex C form
5/23/2011 / 1.7 / Added Modular Approval form
2/6/2013 / 1.8 / Added necessary bandwidth
2/22/2013 / 1.9 / Updated appendix B
9/25/13 / 2.0 / Added IC Site and antenna information to appendix B
IC Application Rev. 2.0Page 1 of 8