775 Montague Expressway
Milpitas, CA 95035
Tel: 408-526-1188
Fax: 408-526-1088
Email: [email protected]
Product Application Questionnaire
Company Information
Manufacturer Information
Factory Information
Local Representative Information
Name:
Address:
Contact Name:
Contact phone:
Contact Fax:
Contact Email:
Name:
Address:
Contact Name:
Contact phone:
Contact Fax:
Contact Email:
When do you need this quote?
When will product be ready to start pre-testing?
Complete pretesting by:
When will product be ready to start formal testing?
Complete formal testing by:
Requested Certifications
Applicable standards information
Have
Need
Safety
EMC
RF/ Wireless
Telecom
1
PTCRB/CTIA/CCF
Yes
No
PTCRB Request #:
Wi-Fi Alliance:
Yes
No
Wi-Fi Alliance Request #:
GCF:
Yes
No
GCF-CC Version:
Other: FCC
IC
CE
Other Countries (see pages 6&7)
Telecom interfaces:
Type:
No#:
Type:
No#:
Equipment Under Test (EUT)
Brand Name:
Model Number or Name:
Description (as it will appear in the test report and grant):
Configuration
Integrated Radio Module(s):
Stand Alone Radio Module(s):
FCC ID:
Radio Hardware Version:
Antenna Options:
Yes
IC ID:
Radio Software Version:
Diversity/MIMO Info:
Antenna:
Multiple
Single
Antenna Design:
Internal
Radio Output Power:
Radio Modules Used: GSM
Audio Support:
No
How Many:
≥ 20 cm
External
< 20 cm
WCDMA
CDMA
WLAN
B/T
Zigbee
RFID
NFC
VoIP
Other
Yes
No
AGPS Mode
Yes
No
Variations to primary device
UE-Based
Yes
Body Proximity:
Handheld
Power Supply:
Distance from Body
Internal
External
No
Worn on body
UE-Assisted
Differences:
MS- Assisted
Held to ear
Explanation
VAC:
VDC:
2
Embedded Radio Modules
PTCRB Certification
Module Manufacturer:
Model #:
IMEI:
Production Numbers:
IMEI SV #:
≤ 10,000
> 10,000
Embedded SIM Socket
Power Interface Changes:
Added SIM Socket
Yes
No
Explain:
Module Changes:
Yes
No
Explain:
Man-machine Interface Changes
Yes
Explain:
No
GSM (2G/2.5G)
Module Make:
FCC ID:
Operating Frequency Bands:
Modulation Type:
Model:
IC ID:
850
GMSK (GSM, GPRS)
900
Power Class:
1800
8PSK (EGPRS)
1900
Multi-slot Power Class:
Antenna Type and Gain:
RF Connector Type:
SMA
UFL
BNC
N
Other:
WCDMA / UMTS (3G)
Module Make:
FCC ID:
Operating Frequency Bands:
FDD I
Model:
IC ID:
FDD II
FDD III
FDD IV
FDD V
FDD VI
FDD VII
FDD VII
FDD IX
TDD
Power Class:
Multi-slot Power Class:
Antenna Type and Gain:
RF Connector Type:
SMA
UFL
BNC
N
Other:
3
CDMA
Module Make:
FCC ID:
Operating Frequency Bands:
Modulation Type:
Model:
IC ID:
800
1700
QPSK / HPSK (CDMA2000)
Power Class:
Antenna Type and Gain:
RF Connector Type:
SMA
1900
HPSK (1xEV-DO)
Multi-slot Power Class:
UFL
BNC
N
Other:
LTE
Model:
IC ID:
Module Make:
FCC ID:
Operating Frequency Bands:
RF Connector Type:
TDD:
Power Class:
Bandwidths supported:
SMA
FDD:
Resource Blocks:
UFL
BNC
N
Other:
WAN
Module Make:
FCC ID:
Operating Frequency Bands:
2.4GHz
UNII-1
ISM
802.11a
2450
5150-5250
802.11b
Model:
IC ID:
UNII-2
UNII-3
CH. 165
5250-5350
UNIIWW/DFS
5470-5725
5725-5850
5805-5845
--
802.11g
--
--
--
--
--
802.11n
--
--
--
--
--
802.11h
DFS
20MHz
40 MHz
Antenna Type and Gain:
RF Connector Type:
SMA
UFL
BNC
N
Other:
4
Bluetooth®
Module Make:
FCC ID:
Modulation Type:
Model:
IC ID:
GFSK
8DPSK (EDR)
π/4
Antenna Type and Gain:
4.0 (LE)
RF Connector Type:
SMA
UFL
BNC
N
Other:
Other Radios
Module Make:
FCC ID:
Operating Frequency Bands:
Multi-slot Power Class:
Antenna Type:
RF Connector Type: SMA
Model:
IC ID:
Modulation Type:
Power Class:
Antenna Gain:
UFL
BNC
N
Other:
Other Radios
Do any radios operate simultaneously:
Yes
If “Yes”, please indicate which ones: Wi-Fi & BT
No
Wi-Fi & GSM or WCDMA or CDMA
BT & FSM or WCDMA or CDMA
Other:
Distance between antennas:
Does this product have CB Test Report?
Yes
No
If yes, CB Certificate No:
If yes, CB Issued Date:
If yes, CB Issued By:
Has the factory been inspected for producing this type of product(s)?
If yes, Factory Inspected by:
If yes, Inspection Report No:
If yes, Factory Inspection Date:
Is this factory ISO 9000 or equivalently Certified?
Yes
Yes
No
No
If yes, ISO 9000 or equivalent standard’s version:
If yes, ISO 9000 or equivalently Certified by:
5
Please indicate which country or countries you’re applying for the Product Certification
United States
Philippines
Canada
Sri Lanka
Austria
South Africa
Belgium
Latvia
Denmark
Poland
Finland
Lithuania
France
Hungary
Germany
Russia
Greece
Slovenia
Iceland
Bulgaria
Ireland
Estonia
Italy
Israel
Liechtenstein
Belarus
Luxembourg
Czech Republic
Norway
Morocco
Portugal
Slovak Republic
Spain
Ukraine
Sweden
Bahrain
Switzerland
Jordan
UK
Oman
Netherlands
Qatar
Croatia
Saudi Arabia
Japan
Kuwait
Australia
Egypt
New Zealand
UAE
India
Brazil
Hong Kong
Mexico
South Korea
Chile
Singapore
Colombia
Thailand
Venezuela
Taiwan
Argentina
PR China
Ecuador
Malaysia
Peru
Indonesia
Vietnam
Other
6
NOTE: Please attach a copy of your product brochure along with data sheets of the radio
modules used in your product(s)
Thank you for considering SIEMIC as your vendor of choice.
You will hear back from us of your inquiry within 24 hours.
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