Quotation for Intentional Radiator

Company Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Phone:

Contact Person:

Email Address:

Product Name or Model

Frequency Range (Please specify units)

Maximum Peak Output Power:

Classify output power rating: Conducted ERP EIRP

Specify type of output power:

Fixed at the Factory Change by the user to any value across a range Switched to specific levels

Specify the modulation type(s):

Describe the modulating signal(s):

Analog Only Digital Only Both Analog and Digital

If applicable, list the available data rates:

List all the antennas to be used with the transmitter Please include the type and gain (dBi) for each antenna.:

Are the antenna(s) detachable?: Yes No

Please give a brief description of how the device operates:

Specify the type of antenna installation:

Portable - Used closer than 20cm to the head or torso Mobile - Used farther than 20cm from the head or torso Fixed, outdoor location

Do you know if your transmitter is subject to SAR/MPE evaluation per 47 CFR 1.1310 and 2.1093?: Yes No I do not know

Is the product used next to?: Head Torso Both

Which body worn accessories are offered (Check all that apply)?: Belt Clips Lanyards Holsters Headsets Others

Company FCC Grantee Code:

Describe the receiver used with the transmitter:

Has the receiver been FCC authorized? Yes No

Which FCC rule parts are applicable to your transmitter?

Can the radio be used with a personal computer through a wired connector? Yes No

If not, is the radio a subassembly or add-in card to a personal computer? Yes No

If not, is the radio a subassembly to a larger device that contains digital electronics? Yes No

Into which countries do you plan to market your product? U.S. Canada Europe

Other:

Who do you want to submit your application to?

Northwest EMC TCB Committee FCC

Do you wish to use Northwest EMC as an agent to assist with the application preparation? Yes No

Any questions or comments?

Please attach any additional information (10mb limit):

May NW EMC contact you in the future about relevant news and events?

Yes No

Northwest EMC