I: Application and Agreement for Certification Services

(RSP-100, Annex A)

(1)  APPLICANT
Applicant Name & Address: / Contact Name: / Telephone:
Email Address: / Fax:
(2)  CANADIAN REPRESENTATIVE
Canadian Rep Name & Address: / Contact Name: / Telephone:
Email Address: / Fax:
Canadian Rep Company Number:
(3)  MANUFACTURER
Manufacturer Name & Address: / Contact Name: / Telephone:
Email Address: / Fax:
Manufacturer Company Number:
(4)  TIMCO CUSTOMER
Customer Name & Address (Main Point of Contact): / Contact Name: / Telephone:
Email Address: / Fax:
PRODUCT INFORMATION
(5) Certification Number consisting of Company Number and UPN (maximum 11 characters) : / IC: -
(6) Hardware Version Id Number (HVIN): *Model Number*
(7) Product Marketing Name (PMN):
(8) Firmware Version Id Number (FVIN):
(9) Host Marketing Name (HMN): / Modular Approval (MA): ☐ / Limited Modular Approval (LMA): ☐
(10) Product Description:
(11) Specification Standard: / Issue #: / Date: / MMYYYY
Issue #: / Date: / MMYYYY
(12) Type of Equipment: / SEARCH - Type of Equipment
(13) Equipment Information: / ☐ Transmitter / ☐ Scanner Receiver
(14) Type of Service: / ☐ New Certification (Single) / ☐ Multiple Listing
☐ New Family Certification / ☐ Full Transfer of TAC
☐ Existing Family/ Modification (C1PC) / ☐ Partial Transfer of TAC
☐ Existing Family/ Modification (C2PC)
☐ Modifications (C3PC)
☐ Modifications (C4PC)
(15) Is this product subject to the TEL Listing per Declaration of Conformity Procedure DC-01 (CS-03) ? / ☐ Yes / ☐ No
(16) AGREEMENT:
THE APPLICANT AGREES TO:
(i.)  Accept responsibility for all TIMCO charges arising from this application;
(ii.)  Meet all requirements in accordance with Radio Standards Procedure 100 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 TIMCO or the Bureau of any changes to the information submitted.
(v.)  Acknowledges that a product cannot be distributing, leased, or offered for sale in Canada until it is listed on the Industry Canada Radio Equipment List (REL).
(vi.)  Acknowledges that TIMCO will need to provide technical information to Industry Canada for inclusion in the REL which may or may not be published on the IC website.
(vii.)  The user notices or statements to the user of equipment will be in both English and French at the time each unit of equipment model is offered for sale and/or lease in Canada.
Name and Title of the Applicant (Please Print or Type): / ☐ Applicant (or)
☐ Authorized Agent
Signature: / Date:

II: Test Report Cover Page/Performance Test Data

(RSP-100, Annex B)

(17) PRODUCT INFORMATION
Certification Number consisting of Company Number and UPN (maximum 11 characters) : / IC: -
Hardware Version Id Number (HVIN): *Model Number*
Product Marketing Name (PMN):
Firmware Version Id Number (FVIN):
IC Test Site Name: / Address:
Phone: / Email:
(18) IC Test Site(s) Reg #: / (19) SAR Lab Company #:
(20) Emissions Information (1)
Band 1 / Band 2 / Band 3 / Band 4 / Band 5 / Band 6 / Band 7 / Band 8
RSS # & Issue #
Technology
(GSM, CDMA, LTE, HSPA, WiMax)
Band Class
Frequency / Min (MHz)
Max (MHz)
RF Power (2)
(or list Field Strength below) / Min (W)
Conducted/ EIRP/ ERP
Max (W)
Conducted/ EIRP/ ERP
Field Strength Units (dBuV)
@ distance (3m, 10m, 30m, 300m)
Measured BW (kHz)
Method (6 dB, 20 dB, 26 dB, 99%, other)
Necessary BW (kHz) (3)
As per TRC-43
Emission Classification
(F1D, G1D, D1D, etc.)
Transmitter Spurious
Units (uV, uW, dBc, dBm, dBw, dBuV)
@ distance (3m, 10m, 30m, 300m)
Receiver Spurious
Units (uV, uW, dBc, dBm, dBw, dBuV)
@ distance (3m, 10m, 30m, 300m)
Antenna Type & Gain
(e.g. “Yagi, 6dBi”)

Notes: (1) Please copy and paste Table 20 above this section if additional bands are required. (2) If relevant, please specify min and max power, and if power is stepped please indicate value. (3): As per TRC-43, if the necessary bandwidth can be calculated, please enter the result; otherwise please enter the measured bandwidth again. (4) Frequency Range = “0.##” ; RF Power = “0.###”; Field Strength = “0.#”

(21) Declaration:
ATTESTATION: The test measurements were made in accordance with the above-mentioned departmental standard(s), and that the equipment identified in this application has been subject to all the applicable test conditions specified in the departmental standards and all of the requirements of the standards have been met.
Name and Title of the Applicant (Please Print or Type):
Signature: / Date:


RSS-102, Annex A – RF Technical Brief Cover Sheet

RF EXPOSURE: SAR and RF (MPE) Evaluation
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:
HVIN:
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/Body-Supported Device; (c) SAR Evaluation: Limb-Worn Device; (d) RF Exposure Evaluation.)
Note: The worst-case scenario (i.e. highest measured value obtained) should be reported.
(a) SAR – HEAD
N/A / N/P / N/V
Multiple simultaneous Tx / Yes / No
Exposure limits used / General Public Use
Controlled Use
Duty Cycle (%)
Standard Used
SAR Value (0.##) / W/kg
Measured Method / Measured
Computed
Calculated
(b) SAR – BODY
N/A / N/P / N/V
Multiple simultaneous Tx / Yes / No
Exposure limits used / General Public Use
Controlled Use
Duty Cycle (%)
Standard Used
SAR Value (0.##) / W/kg
Measured Method / Measured
Computed
Calculated
(c) SAR – LIMB
N/A / N/P / N/V
Multiple simultaneous Tx / Yes / No
Exposure limits used / General Public Use
Controlled Use
Duty Cycle (%)
Standard Used
SAR Value (0.##) / W/kg
Measured Method / Measured
Computed
Calculated
(d)  RF EVALUATION (N/A,N/P, or N/V)
N/A / N/P / N/V
Exposure limits used / General Public Use
Controlled Use
Duty Cycle (%)
Standard Used
Measurement Distance / meter
RF Value (0.##) / V/m / A/m / W/m2
Measured Method / Measured
Computed
Calculated

RSS-102, Annex B

Declaration of RF Exposure Compliance

*Must be signed if Annex A- (a), (b), (c), or (d) has been completed

ATTESTATION: I attest that the information provided in Annex A is correct; that the Technical Brief was prepared and the information contained therein is correct; that the device evaluation was performed or supervised by me; that applicable measurement methods and evaluation methodologies have been followed; 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):

*********************************************************************

RSS-102, Annex C

Declaration of RF Exposure Compliance for Exemption from Routine Evaluation Limits

*Must be signed if Annex A & B are Not Applicable

ATTESTATION: I attest that the radiocommunication apparatus meets the exemption from the routine evaluation limits in Section 2.5 of this standard; that the Technical Brief was prepared and the information contained therein is correct; that the device evaluation was performed or supervised by me; that applicable measurement methods and evaluation methodologies have been followed; 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):

M:\Master Documents\TEMPLATES\DRAFT_IC (Appendix I-II) Form_150702.docx

Rev. 9 July 2015