Application for Equipment Approval and Filing for Telephone Terminal Equipment 739 Issue 7

by TÜV SÜD BABT Operating as a US TCB BABT Page 2 of 6

Introduction

This application form should normally be used for applications for evaluation and approval of a product subject to FCC 47 CFR part 68 by TÜV SÜD BABT as a TCB. It replaces FCC form 730 and includes and interworks with the ACTA submission form. The form consists of a number of individual sections, which should be completed as appropriate.

A.1   Main Contact details

Please write here the company name, and contact details to be used in the progression of the application.

Where they are the same as the responsible party listed in item 4 of the ACTA submission just state “As responsible party”

Title: First name: Last Name:

(This person must be within the organisational structure of the applying company and may not be a consultant)

Job Title and/or Department Reference:

Company Name:

Address:

Postcode/Zip Code: Country:

Prime Telephone Number:

Fax Number:

e-mail Address:

Company Web address:

A.2   Other Contact Information

Normally all contact is directed through the main contact. If you wish to involve others for particular roles please advise TÜV SÜD BABT with their contact details and relationship with the main contact.

In particular please mark with an “X” indicate if you require any of the following and supply the supporting information

A different Company name or address to appear on the certificate from that of the main contact
A Consultant to be involved
{A copy of the authorisation from the applicant company must be provided on company headed paper}

Section B.  Purpose of Application

Please indicate the type of assessment you require by marking all the appropriate boxes:

Application for a Responsible Party Code / Application for an original Equipment approval
Application for a non-Technical change to an existing filing / Application for a technical change to an existing filing

Where you are applying for a change, please provide the TÜV SÜD BABT Certificate number for the original approval: Certificate number: US/......

Application for Equipment Approval and Filing for Telephone Terminal Equipment 739 Issue 7

by TÜV SÜD BABT Operating as a US TCB BABT Page 2 of 6

B.1   Ongoing Surveillance

Please mark with an “X” to indicate which ongoing surveillance option you wish to use:

Manufacture in a TÜV SÜD BABT Certified Manufacturing location (e.g. a location with a PQC or FQA certificate)
Where this option is taken please indicate the Location and Certificate number of your manufacturing location
Location: Cert No.:
Under the TCB market surveillance route

Section C.  Product Details

C.1   Product name and details

Please give the product name(s) which are the subject of this application. Give the name and, if applicable the model or catalogue number of each product. Note Where the product name in supporting documentation differs from that detailed in item 11 of the ACTA submission form please provide an explanation (e.g. The product was known as the “XXy” during development but will be marketed as the “ZZw”).

C.2   Brief Description of this product

Please give brief details of the purpose and type of the product. This is intended to assist in correlating the requested certification with the degree of testing.

C.3   Additional Equipment Authorisation

Is the equipment in this application a composite device subject to an additional equipment authorisation under another part of FCC 47 CFR (indicate as applicable) / Yes / No

If yes please indicate which one of the following is applicable

The related application has been filed at the same time as this application under the FCC ID listed below / Yes / No
The related application has been granted under the FCC ID listed below / Yes / No
The related application is in the process of being filed under the FCC ID listed below / Yes / No
The related application is pending with the TCB/FCC under the FCC ID listed below / Yes / No
The FCC id of the related application is :

Section D.  Payment Details

Work is carried out on receipt of either payment in advance or a valid purchase order number. Clients applying directly to TÜV SÜD BABT (i.e. not through any other TUV Group office), who do not currently have approved credit facilities with TÜV SÜD BABT must include a completed Credit Details Form with the application. Alternatively payment in advance is accepted. The appropriate forms may be downloaded from www.tuv-sud.co.uk/BABT

Where you wish the invoice to be sent to a different person to the main contact please mark “X” in the box and provide the full details in supporting information.
Where you select to use a purchase order please provide your company’s Purchase order number in the box opposite.
Where you wish to pay in advance please either provide details of your credit card or indicate you wish to select this type of payment and contact to arrange for the payment.

Section E.  Agreement

This section must be completed by the applicant named in Section A1

I (We) hereby apply for a Approval of a Telephone Terminal Equipment and agree to conform to the TÜV SÜD BABT Certification Regulations

Signed for on behalf of the applicant

Authorised signatory

Name in CAPITALS Date:

Company Name of Authorised signatory:

All work is undertaken under TÜV SÜD BABT’s standard terms & conditions and the following specific conditions:

·  Certificates only relate to the product and build level of that product identified in the certificate.

·  Certificates are not transferable.

·  Changes to the Holders name or address must be notified to TÜV SÜD BABT Customer Services in writing.

A copy of TÜV SÜD BABT’s standard terms & conditions can be found on our website

This application form must be accompanied by a completed copy of ACTA submission form and the required information as detailed in BABT 738 ‘A guide to applying for US Equipment Approval for telephony terminal equipment through TÜV SÜD BABT as a TCB’

Please send your application to

TÜV SÜD BABT, Octagon House, Concorde Way, Segensworth North, Fareham, Hampshire, PO15 5RL

National Tel: 01489 558306 Fax: 01489 558101

International Tel +44 1489 558306 Fax: +44 1489 558101

Web Address: http://www.tuv-sud.co.uk/babt Email:

Application for Equipment Approval and Filing for Telephone Terminal Equipment 739 Issue 7

by TÜV SÜD BABT Operating as a US TCB BABT Page 6 of 6

Administrative Council for Terminal Attachments

c/o ATIS

1200 G Street, NW

Suite 500

Washington, D.C. 20005

TELEPHONE TERMINAL EQUIPMENT (TTE) SUBMISSION FORM

*Please refer to the Guidelines & Procedures for submittal of information to ACTA for inclusion in the database of approved Telephone Terminal Equipment (“TTE”) for a detailed item description of each field.

1a. Name of Organization Granting Approval NOTE: For SDoC filings only. Information of

or Submitting Request for RPC external company filing for Responsible Party, if applicable

Company Name: / Company Name:
Address: / Address:
City: / State: / Zip: / Country: / City: / State: / Zip: / Country:
Submitter’s Name: / Submitter’s Name:
Phone Number: / Phone Number:
Email Address: / Email Address:
1b. TCB Identification Number (if applicable)
1c. Declaration of Conformity Included? (yes/no)
2. Terminal Approval Date
3. Product Identifier

4. Responsible Party 5. U.S. Agent for Service

Company Name: / Company Name:
Address: / Individual or Department
City: / State: / Zip: / Country: / Address:
Responsible Party Point of Contact: / City: / State: / Zip:
Phone Number: / Phone:
Email Address: / URL:

6. Equipment Description 6a. Country of Origin

Application for Equipment Approval and Filing for Telephone Terminal Equipment 739 Issue 7

by TÜV SÜD BABT Operating as a US TCB BABT Page 6 of 6

7. Responsible Party Code (RPC) 8. Manufacturer’s Code (if available)

9.  Current Authorization Number (only if

Modification, Notice, Re-certification, and/or

Re-declaration Filing) 10. Equipment Code

11a. List of Brand or Trade Name(s) Including New and Existing Names
11b. List of New and Existing Model Number(s) for Each Brand or Trade Name

12. Network address signaling code

13a. AC Ringer Equivalence Number (REN) / 13b. Hearing Aid Compatibility (YES/NO/NA)
13c. USOC Jack(s) / 13d. Repetitive Dialling to a Single Number
(YES/NO)

14. Filing Status

15. Facility Interface Code(s) 16. Manufacturer Port ID

17. Service Order Code(s) (SOC) 18. Answer Supervision Code(s)

19.  Ancillary Equipment

Certification
Status / Trade Name / Model Number / List of Ancillary Equipment by Type / Manufacturer’s Identifier
1.
2.
3.
4.

If you are submitting an original filing or re-certification please fill out the following information. This will give you your ACTA Product-Labelling Number.

ACTA PRODUCT LABEL
US:

#7 #10 #13a (leave out #3

The decimal point)

#7. Responsible Party Code (RPC)

#10. Equipment Code

#13a AC Ringer Equivalence Number (REN)

#3. Product Identifier