FEDERAL   COMMUNICATIONS   COMMISSION                                                                            Approved by OMB

Washington, Dc 20884                                                                                                                                                                                3060- 0059                                                                                                                                

                                                                                                                                                                                                                              Expires  7/31/94

 

STATEMENT  REGARDING   THE   IMPORTATION   OF   RADIO  FREQUENCY   DEVICES

CAPABLE   OF   CAUSING   HARMFUL   INTERFERENCE

 

AWB No:                                                                                                                  Return To:                                           

 

PART    I  - All Blocks MUST  Be Completed
Date of Entry	Entry Number	Port of Entry 1		Harmonized  tariff  Number  2		Quantity  of  Item (not container) 3
Model/Type Name  or  Model/Type Number			Trade Name	FCC  ID Number	Description of  Equipment
Manufacturer’s   Name and  Address				Importer’s Name and Address
				Signature  of  Importer   or  Consignee			Date
Consignee’s  Name  and  Address
				Printed  or  Typed  Name  of  Importer  or  Consignee

WARNING :      Any person who knowingly makes a false declaration may be fined not more than

                       $ 250,000 or imprisoned  not more than 5 years, or both, pursuant to 18 U.S.C. 1001.

 

PART    II -  With regard to the Importation of the described Radio Frequency Device,    I  DECLARE  THAT:

(Place an X in only one box)

	1.    An equipment authorization has been issued by the FCC.
	2.    An equipment authorization is not required but the equipment complies with FCC technical requirements
	3.     The described equipment is being imported in limited quantities for testing and evaluation for   compliance with technical requirements or marketing suitability. The equipment will not be offered for sale or otherwise marketed. (See instructions.)
	4.     The described equipment is being imported in limited quantities for demonstration at industry trade shows and will not be offered for sale or otherwise marketed. (See instructions.)
	5.     The described equipment is being imported solely for export. It will not be offered for sale or otherwise marketed in the U.S.
	6.     The described equipment is being imported  for use exclusively by the U.S. Government.
	7.     Three or fewer radio receivers, computers, or other unintentional radiators as defined in Part 15 of the FCC rules are being imported for an individual’s personal use and are not intended for sale.
	8.     The described equipment is being imported  for repair and will not be offered for sale or otherwise marketed.

1         Port of Entry Use Schedule D – Classification of U.S. Customs Districts and Ports for U.S. Foreign Trade Statistics – a four digit code, i.e., New York City, NY 1001.

2         Harmonized tariff Number  - Harmonized tariff  Schedule of  the United States.

3         This quantity must be total number of items, not number of containers.