STATEMENT REGARDING THE IMPORTATION OF RADIO

Approved by OMB
3060-0059
FEDERAL COMMUNCATIONS COMMISSION
Washington, D.C. 20554
STATEMENT REGARDING THE IMPORTATION OF RADIO FREQUENCY DEVICES CAPABLE OF
CAUSING HARMFUL INTERFERENCE
Part I
(Read instructions before completing form. Please type or print clearly in ink.)
Part I の①から⑩をご記入ください。
⑨と⑩については発送人様の名前・署名で構いません。
MUST
All Blocks
-- All
Blocks MUST Be
Be Completed
Completed
Harmonized Tariff Number 2
Date of Entry
Entry Number
Port of Entry 1
――――――
ご記入の必要はございません
Device Model/Type Name or #
②型番
Trade Name
③ブランド名
（例：ABCMC）
Manufacturer’s Name and Address
⑥製造者
(例：ABC International JAPAN
1-1-1 Yamaue-cho Yamashita-shi
Kanagawa 222-0000 Japan)
Quantity of Item (not number of containers) 3
――――――
FCC ID
①型番ごとの数量
Description of Equipment
④FCC ID番号
(不明の場合は空欄でよい)
Consignee’s Name and Address
⑤品名（例：Notebook PC）
Importer’s Name and Address
⑦荷受人
⑧輸入者
(例：XWZ International USA
1111 New York, NY 10000 USA)
(荷受人と同一の場合は、
Same as Cosigneeと記入すればよい
Printed or Typed Name of Importer or Consignee
Signature of Importer or Consignee
⑨発送人の名前
Date (Month/Day/Year)
⑩発送人の署名　/　日付(例： August 25, 2011)
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 -
Part ＩＩの1から8のうち、該当する項目に１つチェックを入れてください。
I DECLARE THAT:
1.
FCCの許可番号が与えられている。(Part I の④にFCC IDを記入した場合は、この項目を選択してください)
2.
FCCの許可番号は要求されないが、FCC技術要件に合致している。
3.
検査と評価の為に限られた台数を輸入するもので、販売はしない。
4.
工業用見本市で実演する為に限られた台数を輸入するもので、販売はしない。
5
米国から米国外へ輸出する為に単純に日本から米国へ送るため、米国内での販売はしない。
5(a). 米国規格外のため、米国内で使用不可な携帯電話である。
6.
米国政府の使用の為だけに米国へ輸入するものである。
7.
個人使用目的で3台以下の機器を米国へ輸入するもので、販売はしない。
8.
修理の為に米国に輸入するもので、販売はしない。
1.
2.
3.
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.
Harmonized Tariff Number – Harmonized Tariff Schedule of the United States.
This quantity must be total number of items, not number of containers.
FCC Form 740
March 2004
FEDERAL COMMUNCATIONS COMMISSION
Washington, D.C. 20554
Approved by OMB
3060-0059
STATEMENT REGARDING THE IMPORTATION OF RADIO FREQUENCY DEVICES CAPABLE OF
CAUSING HARMFUL INTERFERENCE
(Read instructions before completing form. Please type or print clearly in ink.)
Part I - All Blocks MUST Be Completed
Date of Entry
Entry Number
Device Model/Type Name or #
Port of Entry1
Trade Name
Manufacturer’s Name and Address
Printed or Typed Name of Importer or Consignee
Harmonized Tariff Number2
Quantity of Item (not number of containers)3
FCC ID
Consignee’s Name and Address
Description of Equipment
Importer’s Name and Address
Signature of Importer or Consignee
Date (Month/Day/Year)
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(s), I DECLARE THAT:
(Place an “X” in only one box)
1. The FCC has issued a grant of equipment authorization for the FCC ID listed above.
2. An FCC grant of equipment authorization and an FCC ID are 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.
5(a). The described equipment is a non-U.S. standard cellular phone that can only function outside of the U.S. (See Instructions)
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.
2.
3.
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.
Harmonized Tariff Number – Harmonized Tariff Schedule of the United States.
This quantity must be total number of items, not number of containers.
FCC Form 740
March 2004

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