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Transmitter / Receiver Information Request (for providing testing plan / quote) * Denotes required information *Contact Information Name: Company: Phone No: Fax No: Email Address: Street: City: State: Zip Code: *Equipment to be tested Model Name/Number: Serial Number: Formal Name: Equipment is: *Intended market: Receiver U.S. Transmitter Canada Transceiver Other: Emission Designator (if known) Requested standards (if known) that apply to this device: USA: Canada: EU: Other: Page 1 of 4 *Is the RF module purchased? Yes No *If Yes, does the module have a FCC Modular Approval? Yes No List the FCC ID# Is a FCC Modular Approval requested? Yes No *Define the intended use for this device: *Does this device operate/tune over multiple channels? Yes No *List all channels / frequencies used by the device under test: Has this device been previously tested/approved to this or any other EMC standard? Yes IF ‘YES’: No Approval Number(s) Date(s) Issuing Authority Power Source (DC): Battery operated? Nominal rated Voltage: Minimum rated Voltage: Maximum rated Voltage: Power Source (AC): Nominal rated Voltage: Minimum rated Voltage: Maximum rated Voltage: Line Frequency: Single or 3-Phase: Maximum current: Page 2 of 4 Receiver Specific: *Nominal receive frequency (or tunable range) *Receiver is: superheterodyne superregenerative other: Channel separation *Maximum number of channels over which equipment can operate: Transmitter Specific: *Nominal transmit frequency: *Equipment is classified as: *Equipment has: fixed mobile portable hand-held Integral antenna Single antenna connector Double antenna connector *Type of antenna connector(s) (if equipped): Antenna Gain (if known): Method of frequency generation (crystal, Synth., other): Transmitter Power: *Rated output power at the antenna connector(s) (if equipped): *Is the output power variable? Yes No If ‘YES’: What is the minimum RF power: What is the maximum RF power: Class of emission (if known): Type designation: Type of modulation: What % : *Can transmitter operate unmodulated ? Yes No Is device intended for continuous operation (duty cycle = 100%): Page 3 of 4 Yes No Should DLS take the required filing photos? (If not, you must provide these photos in digital format before DLS can submit filing): Yes No Is device intended for intermittent operation? Transmit ON time (if applicable) Transmit OFF time (if applicable) Duty cycle = Tx ON / (Tx ON + Tx OFF) = Yes No (if applicable) *Is continuous operation possible for testing purposes? What will be used for test? (Max. duty cycle possible) Transmit ON time (if applicable) Transmit OFF time (if applicable) Duty cycle = Tx ON / (Tx ON + Tx OFF) = Yes No (if applicable) Does the device have a port for an input modulation signal? _ If ‘YES’: Input signal level Input signal impedence () Type of modulation Percent Audio limiting? Maximum modulation depth Yes Extreme temperature range over which the equipment is to be tested: Category 1: -20 C to +55 C Category 2: -10 C to +55 C Category 3: 0 C to +55 C (General) (Portable) (Normal indoor use) Page 4 of 4 No