TCB Application Form 731 AN IIA COMPANY Item 1. Grantees complete, legal business name:
List the Grantee company name as it is listed in FCC database. AUTOMATIC TECHNOLOGY (AUSTRALIA) PTY LTD Grantees FCC Registration Number (FRN):
Item 2. Grantees Mailing Address (as it is listed in FCC database) 0019477462 Line 1: 6-8 FIVEWAYS BOULEVARD, KEYSBOROUGH Line 2:
State/Province: VICTORIA Country: AUSTRALIA City:
Zip/Postal Code: 3173 Item 3. Grantee Contact Person Must be the same as the FCC Grantee contact listed in the FCC database. The name listed in the FCC Database will be on the Grant. https://fjallfoss.fcc.gov/oetcf/eas/reports/GranteeSearch.cfm First Name (Given Name): Nikolai Last Name (Family Name): Klepikov Title: Senior Electronics Design Engineer Telephone: +61 3 9791 0200 Fax No. (if applicable): +61 3 9791 0250 Equipment Product Code: -TRX02403 14 characters maximum including hyphens. All correspondence regarding this application will be directed to this contact including, but not limited to requests for additional information, the Grant, and the invoice. Telephone:
+61 3 9365 1000 Fax: No. (if applicable):
+61 3 9331 7455 Ext:
Email Address:
Item 4. FCC ID Item 5. Timcos Customer Grantee Code: X4K Customer Company Business Name:
EMC Technologies Pty Ltd Email Address: chris@emctech.com.au Line 1: 176 HARRICK ROAD, KEILOR PARK Line 2:
First Name (Given Name): Chris Last Name (Family Name): Zombolas State/Province: Victoria Country: Australia Item 6. Test Firm Used to Take Measurements Test Lab Company Business Name:
EMC Technologies Pty Ltd First Name (Given Name): Chris Address Line 1: 176 HARRICK ROAD, KEILOR PARK Address Line 2:
Ext.:
Telephone:
+61 3 9365 1000 Last Name (Family Name): Zombolas Fax No.:
+61 3 9331 7455 City: Melbourne Zip/Postal Code: 3042 City: Melbourne State/Province: Victoria Country: Australia Zip/Postal Code: 3042 Email Address: chris@emctech.com.au Item 7. Does this application include a request for PERMANENT confidentiality for any portion(s) of the data contained in this application pursuant to 47 CFR 0.459 of the Commission Rules?
Does this application include a request for SHORT-TERM confidentiality for any portion(s) of the data contained in this application pursuant to FCC DA 04-1705 dated 06/15/2004?
Permanent Confidentiality Requested:
X Yes No Short-term Confidentiality Requested:
Yes X No If yes, must indicate number of days below. 45 days 90 days 180 days Other:
Request for Grant Deferral:
Yes:
No: X Date:
849 NW State Road 45, Newberry, Florida 32669
(352) 472-5500 Certification: cb@timcoengr.com Testing: testing@timcoengr.com www.timcoengr.com TCB Application Form 731 AN IIA COMPANY Item 8. Is this application for modular approval? X Yes No Modular Type: Only complete if you answered Yes to Item 8. Single Modular Approval X Limited Single Modular Approval Split Modular Approval Limited Split Modular Approval Item 9. Is this application for software defined radio authorization?
Yes X No Item 10. Enter a brief description of the product being marketed. AUTO-KI SMART MODULE FOR HIRO (Maximum 255 Characters) Item 11. This Application is for:
Original Equipment Change in identification of presently authorized equipment:
Original FCC ID: Grant Date (MM/DD/YYYY):
X Class II permissive change or modification of presently authorized equipment Class III permissive change to software defined radio (Note: this may only be filed for applications pertaining to Software Defined Radio) Item 12. Is the equipment in this application:
(a) a composite device subject to an additional equipment authorization?
(b) part of a system that operates with, or is marketed with, another device that requires an equipment authorization?
12 (c) The related application:
Note: If either of the above questions have been answered with Yes complete section 12 (c). has been granted under the FCC ID(s) listed to the right is in the process of being filed under the FCC ID(s) listed to the right is pending with the FCC under the FCC ID(s) listed to the right has a mix of pending and granted statuses under the FCC ID(s) listed to the right Item 13. Equipment Specifications Line Item #
Frequency range in MHz Low Freq. High Freq. Rated RF Power Output IN WATTS Frequency Tolerance Value
%, Hz, ppm Emission Designator
(See 47 CFR 2.201 and 2.202) 912.5 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 926.9 0.09
(a) Yes No
(b) Yes No i. ii. iii. iv. FCC ID:
FCC ID:
FCC ID:
FCC ID:
Optional FCC Rule Part Equipment Class Grant Notes
(Example- CC, MO) 15.247 DSS 849 NW State Road 45, Newberry, Florida 32669
(352) 472-5500 Certification: cb@timcoengr.com Testing: testing@timcoengr.com www.timcoengr.com TCB Application Form 731 Item 14. Equipment Authorization Waiver Is there an equipment authorization waiver associated with this application?
If there is an equipment authorization waiver associated with this application, has the associated waiver been approved and all information AN IIA COMPANY Yes No uploaded?
Yes No Read each certification carefully before answering and signing this application. WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1)), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503). SECTION 5301 (ANTI-DRUG ABUSE) CERTIFICATION:
The applicant must certify that neither the applicant nor any party to the application is subject to a denial of Federal benefits, that include FCC benefits, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. 862 because of a conviction for possession or distribution of a controlled substance. See 47 CFR 1.2002(b) for the definition of a "party" for these purposes. Does the applicant or authorization agent so certify?
Yes No Item 15. APPLICANT/AGENT CERTIFICATION:
I certify that I am authorized to sign this application. All of the statements herein and the exhibits attached hereto, are true and correct to the best of my knowledge and belief. In accepting a Grant of Equipment Authorization as a result of the representations made in this application, the applicant is responsible for (1) labeling the equipment with the exact FCC ID specified in this application, (2) compliance statement labeling pursuant to the applicable rules, and (3) compliance of the equipment with the applicable technical rules. If the applicant is not the actual manufacturer of the equipment, appropriate arrangements have been made with the manufacturer to ensure that production units of this equipment will continue to comply with the FCC's technical requirements. Authorizing an agent to sign this application, is done solely at the applicant's discretion; however, the applicant remains responsible for all statements in this application. If an agent has signed this application on behalf of the applicant, a written letter of authorization which includes information to enable the agent to respond to the above section 5301 (Anti-Drug Abuse) Certification statement has been provided by the applicant. It is understood that the letter of authorization must be submitted to the FCC upon request, and that the FCC reserves the right to contact the applicant directly at any time. If signee listed below is different from Grantees contact (Item 3) you must supply a Letter of Authorization. This authorization letter must be signed by the applicant / grantee (Item 3). The authorization letter MUST name the person that they are authorizing to sign on their behalf. Signature of Authorized Applicant (Must be actual signature):
Name & Title of Authorized Signature (Typed): Chris Zombolas, Technical Director Company Name of Person Signing Application: EMC Technologies Pty Ltd 849 NW State Road 45, Newberry, Florida 32669
(352) 472-5500 Certification: cb@timcoengr.com Testing: testing@timcoengr.com www.timcoengr.com