用戶室內(nèi)設(shè)備驗(yàn)證申請表

1、用戶室內(nèi)設(shè)備驗(yàn)證申請表Application Form for Certification of Customer Premises Equipment申請表格號(hào)碼:Form Number: LCBForm-002c遞交申請表格Submission of Completed Forms地址:天祥公證行有限公司, 商用及電子電器部(電訊組)香港九龍青山道五七六號(hào)製衣工業(yè)中心二字樓Address:Intertek Testing Services Hong Kong Ltd., C&E Division (Telecommunications)2/F., Garment Centre, 5

2、76 Castle Peak Road, Kowloon, Hong Kong電話: 傳真:Tel.: +852 2173 8536Fax: +852 2741 1693申請人須知Notes to Applicants:1. 透過本表格提供個(gè)人資料，屬自願(yuàn)性質(zhì)。如你沒有提供足夠資料，本公司可能無法辦理你的申請。The provision of personal data by means of this application form is voluntary. If you do not provide sufficient information, we may not be able

3、to process your application.2. 你所填寫的個(gè)人資料，將被天祥公證行有限公司用以處理你的申請。The personal data provided by you will be used by Intertek Testing Services HK Ltd. for processing your application made in this form.3. 在評估你的申請時(shí)，或會(huì)向相關(guān)政府部門 / 機(jī)構(gòu)披露你在本表格所提供的個(gè)人資料。除個(gè)人資料外，本公司或會(huì)向香港認(rèn)可處披露你所提交無線電設(shè)備的有關(guān)資料，惟只作認(rèn)可之用。The personal data yo

4、u provide by means of this form may be disclosed to relevant government departments /agencies in connection with the assessment of your application. In addition to the personal data, any relevant information related to the radio equipment as submitted with your application may be disclosed to Hong K

5、ong Accreditation Service (HKAS) for the purpose of accreditation only.4. 你有權(quán)要求查閱和更正你的個(gè)人資料。包括取得本申請表上所載個(gè)人資料的副本，惟索取這些資料時(shí)或須繳費(fèi)。You have a right of request for access and correction with respect to personal data. Your right of access includes the right to obtain a copy of your personal data provided by t

6、his application form, though a charge may be levied on obtaining such information.5. 如對透過本申請表所收集的個(gè)人資料有問題，包括如何提出查閱和改正個(gè)人資料的要求，請聯(lián)絡(luò)天祥公證行有限公司, 香港九龍青山道五七六號(hào)製衣工業(yè)中心二字樓經(jīng)辦人: 商用及電子電器部(電訊組)電話: +852 2173 8536傳真: +852 2741 1693Enquiries concerning the personal data collected by means of this form, including the ma

7、king of request for access and correction should be addressed to:Intertek Testing Services Hong Kong Ltd.2/F., Garment Centre, 576 Castle Peak Road, Kowloon, Hong Kong Attn: C&E Division, (Telecommunications)Tel.: +852 2173 8536 Fax: +852 2741 1693填表指引1. 每份申請表只可填寫一種設(shè)備的型號(hào)或類型編號(hào)。2. 請以正楷填妥所有有關(guān)部份，並須在

8、不適用處填上不適用。3. 在適當(dāng)?shù)膬?nèi)加上號(hào)。4. 請參閱夾附的填寫須知；該指引提供有用的資料，協(xié)助閣下填寫本申請表。如對本申請表有任何疑問，請致電 +852 2173 8536 、以傳真（傳真號(hào)碼：+852 2741 1693）或電郵（地址：lcb.hk ）與我們聯(lián)絡(luò)。5. 填妥的表格須連同所需的證明文件及申請費(fèi)用，送交天祥公證行有限公司, 商用及電子電器部(電訊組), 香港九龍青山道五七六號(hào)製衣工業(yè)中心二字樓。6. 在接獲天祥公證行有限公司通知前，無需送交設(shè)備樣本。7. 如在本表格提供的資料不正確或有不完整，可能會(huì)導(dǎo)致申請被拒或?qū)硪寻l(fā)的證書被撤銷。Instruction for compl

9、etion1. Use one application for only one model or type number of the equipment.2. Please complete all relevant parts in BLOCK letter. If a part is not applicable, please write “N/A”. 3. tick where appropriate.4. Please refer to the accompanying guidance notes which offer some useful information to h

10、elp complete this form. For further enquire about this application form, please contact Intertek Testing Services HK Ltd by phone at +852 2173 8536, by fax at +852 2741 1693 or e-mail at lcb.hk5. The complete form, together with the required supporting documents and application fee, should be return

11、ed to Intertek Testing Services HK Ltd, 2/F., Garment Centre, 576 Castle Peak Road, Kowloon, Hong Kong.6. No equipment sample is to be sent until advice from Intertek Testing Services HK Ltd.7. Incomplete or incorrect information supplied on this form may result in rejection of the application or su

12、bsequent withdrawal of the certificate granted.甲部 - 申請人資料PART A - PARTICULARS OF APPLICANT （請參閱須知第 1 項(xiàng)）(See NOTE 1)公司名稱:Company Name:英文、請用正楷 (In English BLOCK LETTERS)中文、如適用 ( In Chinese, if applicable)公司地址Company Address:無線電商(放寬限制)牌照號(hào)碼（如適用） Radio Dealers (Unrestricted) License No. (if applicable) R

13、U 在貴公司負(fù)責(zé)這項(xiàng)申請人士的姓名，電話號(hào)碼、傳真號(hào)碼及電郵地址：Give the name, telephone number, facsimile number and email address of the person in your company who is responsible for this application:姓名 英文Name ( In English ): 中文、如適用( In Chinese, if applicable) (先生)(Mr.) (女士)(Ms.)電話號(hào)碼Telephone No.:傳真號(hào)碼Fax No.:電郵地址Email Address:

14、只供本公司使用For Official Use OnlyApplication No.: _Job Reference: _甲 部 - 申請人資料 (續(xù))PART A - PARTICULARS OF APPLICANT (contd)(若你想授權(quán)代理人代你申請類型檢定或類型認(rèn)可，請?zhí)顚懴铝匈Y料。一份由申請人簽發(fā)委託代理人代為申請類型檢定或類型認(rèn)可的授權(quán)書必須連同申請表格一併遞交。你並非必須委託任何人代你申請。)(Complete only if you wish to authorize an agent to apply for type approval or type acceptan

15、ce on your behalf. A letter of authorization from the Applicant authorizing the agent to apply for type approval or type acceptance on the Applicant's behalf must be enclosed with this application form. Authorization is NOT compulsory.)授權(quán)代理人的公司名稱: Company Name of Authorized Agent:公司地址Company Add

16、ress:聯(lián)絡(luò)人姓名英文Name ( In English ): 中文、如適用( In Chinese, if applicable) (先生)(Mr.) (女士)(Ms.)電話號(hào)碼Telephone No.:傳真號(hào)碼Fax No.:電郵地址Email Address: 乙 部 生產(chǎn)商資料PART B - PARTICULARS OF MANUFACTURER生產(chǎn)商名稱:Manufacturer Name:英文、請用正楷 (In English BLOCK LETTERS)中文、如適用 ( In Chinese, if applicable)生產(chǎn)商地址:Manufacturer Address

17、:聯(lián)絡(luò)人姓名 英文Name of Contact Person( In English ): 中文、如適用( In Chinese, if applicable) (先生)(Mr.) (女士)(Ms.)電話號(hào)碼Telephone No.:傳真號(hào)碼Fax No.:電郵地址Email Address: 丙 部 - 用戶室內(nèi)設(shè)備資料PART C - DETAILS OF CUSTOMER PERMISES EQUIPMENT（請參閱須知第 2-3 項(xiàng)）(See NOTE 2-3)1.適合的 HKTA 規(guī)格: Applicable HKTA Specification(s): 2.設(shè)備類別:Type

18、of Equipment: 3. 牌子:Brand Name:5. 其他型號(hào)(如有)Variants (if any):4. 型號(hào):Model No.:6. 製造年份:Year of Manufacture:7.有否獲任何證書: 有 沒有Any certificate(s) received: Yes No如有:if yes證書編號(hào)Certificate No驗(yàn)證當(dāng)局Issuing Authority相關(guān)標(biāo)準(zhǔn)Relevant Standard丁 部 - 文件PART D - DOCUMENTATION（請參閱須知第 3-8 項(xiàng)）(See NOTE 3-8)遞交文件：支付天祥公證行有限公司的港幣

19、元款項(xiàng)。The appropriate fee of HK Dollars payable to “Intertek Testing Services HK Ltd”(如經(jīng)網(wǎng)上申請，可郵寄劃線支票、銀行本票或銀行匯票至天祥公證行有限公司香港九龍青山道五七六號(hào)製衣工業(yè)中心二字樓收。)(If the application is submitted online, you may send a crossed cheque, cashier order or bank draft by post to Intertek Testing Services HK Ltd, 2/F., Garment

20、Centre, 576 Castle Peak Road, Kowloon, Hong Kong.)註明元件數(shù)值及容限的電路圖乙份。One set of circuit diagram(s) giving values and tolerance of components詳細(xì)描述設(shè)備及其操作的技術(shù) / 操作手冊副本乙份。One copy of technical / operating manual giving a detailed description of the equipment and its operation.詳細(xì)方塊圖副本乙份。One copy of block diag

21、rams of circuitry.廣告資料乙份。One copy of advertising material(s).展示設(shè)備外觀包括所有控制按鈕、開關(guān)及指示器的照片 / 產(chǎn)品小冊子。Photographs / product brochure showing the appearance of the equipment including all control buttons, switches and indicators認(rèn)可測試代理商的測試報(bào)告乙份。One copy of test report issued by Recognised Testing Agency (RTA).

22、IEC60950 / EN60950 / UL60950 的電氣安全證書或測試報(bào)告乙份。One copy of electrical safety certificate or test report against IEC60950 / EN60950 / UL60950電氣產(chǎn)品(安全)規(guī)例下的符合安全規(guī)格證明書乙份，只適用於在設(shè)計(jì)上是供家庭使用的電氣設(shè)備。One copy of “Certificate of Safety Compliance” under Electrical Products (Safety) Regulations, only applicable to elect

23、rical equipment designed for household use其他文件（請?jiān)]明）Any other document(s), please specify:備註: 接受以上文件的電子複本。Remark: Electronic copy of the above documents is also accepted.戊 部 - 申請人聲明PART E - DECLARATION OF APPLICANT致: 天祥公證行有限公司To: Intertek Testing Services HK Ltd本人/我們謹(jǐn)此聲明，本申請表填報(bào)的資料和夾附的文件均屬真實(shí)，完整及正確無誤。I

24、/We hereby declare that the information and document given in this application form is true, correct and complete.申請人公司/機(jī)構(gòu)印鑑Applicant's Company/Organization Chop 申請人簽署: Signature of Applicant:簽署人姓名: Signatory's full name: 請用正楷書寫 (In BLOCK LETTERS)職位:Position Held: 日期 Date: 填 寫 表 格 LCBForm-00

25、2 須 知1.申請人一般須為有關(guān)設(shè)備的製造商或其授權(quán)代表、或設(shè)備供應(yīng)商。若申請人是測試代理商或顧問，則需提交一封由設(shè)備製造商的授權(quán)信件以表明該申請人是獲授權(quán)代表設(shè)備製造商提交驗(yàn)證申請。2.丙部所填寫的牌子及型號(hào)須能用以清楚辨認(rèn)正在申請驗(yàn)證的設(shè)備。假如丙部所載的牌子及型號(hào)，與申請人所提交的有關(guān)證書或測試報(bào)告有出入，申請人須提供詳細(xì)的解釋及製造商的聲明，以證明正在申請驗(yàn)證的設(shè)備， 與申請人所提交的證書或測試報(bào)告的設(shè)備的電力及機(jī)械規(guī)格完全一致。3. HKTA 規(guī)格訂明用戶室內(nèi)設(shè)備的技術(shù)規(guī)定，有關(guān)詳情載於：.hk/zh/standards/HKTASpec/hkta

26、-2xxx.html?；旧?，很多種類的用戶室內(nèi)設(shè)備均沒有強(qiáng)制驗(yàn)證的規(guī)定，只要符合指定的 HKTA 規(guī)格，便可在本地市場出售。請參閱編號(hào) OFTA I 421 的電訊設(shè)備鑑定及驗(yàn)證計(jì)劃資料便覽：.hk/zh/tec/information-notes/in421.pdf。申請人通?？蓮母鶕?jù)測試機(jī)構(gòu)按有關(guān) HKTA 規(guī)格對設(shè)備的樣本所進(jìn)行測試的結(jié)果獲取驗(yàn)證。測試機(jī)構(gòu)指認(rèn)可測試代理商。請參閱編號(hào) OFTA I 411 的為電訊設(shè)備進(jìn)行鑑定測試的認(rèn)可測試代理商資料便覽：.hk/zh/tec/information-notes/i

27、n41198.html 內(nèi)有關(guān)於認(rèn)可測試代理商的定義。4. 如對測試報(bào)告的詮釋、進(jìn)行測試的方法和設(shè)備製造商所提交的聲明的真確性有任何爭議，以天祥公證行有限公司的決定為準(zhǔn)。5. 不完整、不充足或不適當(dāng)?shù)奈募驎?huì)導(dǎo)致申請進(jìn)度受阻甚至申請被拒。申請人因此應(yīng)確保所提交的文件完整及準(zhǔn)確。所有用以支持申請的文件，包括測試報(bào)告、證書等，均須以中文或英文撰寫。如證明文件是以其他語言撰寫，申請人須提供經(jīng)認(rèn)證的中文或英文譯本。這些證明文件宜以光碟或其他電子形式提交。6. 申請費(fèi)用及其他額外資料可參閱編號(hào) OFTA I 412 的怎樣申請為連接本港公共電訊網(wǎng)絡(luò)的用戶室內(nèi)設(shè)備驗(yàn)證資料便覽：http:/www.ofta

28、.gov.hk/zh/tec/information-notes/in412.pdf 。申請費(fèi)用須在遞交申請時(shí)繳付。7. 可以支票、銀行本票或銀行匯票方式繳付申請費(fèi)。劃線支票、銀行本票或銀行匯票須註明支付予天祥公證行有限公司。由海外銀行發(fā)出的銀行匯票所填款額須包括本地銀行收取的費(fèi)用。請於支票、銀行本票或銀行匯票背面寫上申請人的姓名及申請檢定的設(shè)備型號(hào)。8. 如申請獲得批準(zhǔn)，天祥公證行有限公司會(huì)保留申請人提交的所有技術(shù)文件。如申請不獲批準(zhǔn)，申請人將獲通知有關(guān)結(jié)果。- 完 -Guidance Notes For Completion of LCBForm-0021. Applicants are

29、normally the manufacturers of the equipment, or its authorised representatives, or equipment suppliers. In case the applicant is a testing agency or consultant, an authorisation letter from the equipment manufacturer indicating the applicant is acted on behalf of the equipment manufacturer in applyi

30、ng for certification should be submitted.2. Brand name and model number given in Part C should be able to uniquely identify the equipment under application. In case that the brand name and model number as given in Part C are different from those in the submitted certificate or test report, the appli

31、cant should provide detailed explanation and a manufacturer's declaration to confirm that the equipment under application is electrically and mechanically identical to the one covered by the submitted certificate or test report.3. The technical requirements for customer premises equipment are pr

32、escribed in the HKTA specifications, which are published in details at .hk/en/standards/HKTASpec/hkta-2xxx.html. Basically, certification is not a mandatory requirement for many types of customer premises equipment, which can be placed in the local market without certification prov

33、ided that they comply with the prescribed HKTA specifications. Applicant is advised to refer to information note OFTA I 421 “Hong Kong Telecommunications Equipment Evaluation and Certification (HKTEC) Scheme” at .hk/en/tec/information-notes/in421.pdf for details of certification sc

34、hemes in Hong Kong. Usually, certification can be obtained based on the result of tests on samples of the equipment conducted by a testing body against the relevant HKTA specification. The testing body refers to a Recognised Testing Agency (RTA). Please refer to the information note OFTA I 411 “Reco

35、gnised Testing Agency (RTA) for Conducting Evaluation Test of Telecommunications Equipment” at .hk/en/tec/information-notes/in41198.html for definition of RTA. 4. In cases of doubt relating to the interpretation of the test report, the method of carrying out the tests and the valid

36、ity of the statements made by the manufacturers of the equipment, the decision of the Intertek Testing Services HK Ltd. should be final.5. Incomplete, inadequate or improper documentation may cause delay or reject of an application. The applicant is requested to pay attention to ensure the completeness and accuracy of documentation. All supporting documents, including the test report, certificate etc., should be in either Chinese or English language. For those