FORM CSF410-TCB FCC APPLICATION FORM This form constitutes the certification agreement between Element Materials Technology and the Applicant and is required for every application. Please ensure accuracy when completing this form because the content is used to make the FCC upload to the FCC eFiling system. Please complete the relevant sections in the tables below. Guidance on each numbered section of this form is provided at the end of the document. Please contact Element if you have any further questions. Applicant business details 1. Applicants complete, legal business name. 2. Applicants mailing address
(Line 1) 3. Applicants mailing address
(Line 2) 4. City, State, Zip (or postal code) 5. Name, Title of Person registered with the FCC to receive the grant. 6. Phone No. (Area/Country
/City Code, Number, Ext). GKD Technik Limited 17 Cobham Road Wimborne, Dorset, United Kingdom, BH21 7PE Mr Matt OBrien
+44(0)1202 861961 7. Fax No. (Area/Country/City Code, Number, Ext.
+44(0)1202 861961 8. Internet email address accounts@gkdtec.com 9. Applicants FRN # (FCC registered number) 0031119191 Authorised agent details Only to be completed where a third party is used to make an application on behalf of the Applicant 10. Name, Title Rowan Beale, Senior Consultant 11. Mailing address (Line 1) 12. City, State, Zip (or postal code) 42 Technology Ltd, 5-6 The Meadow, Meadow Lane St Ives, Cambridgeshire, PE27 4LG 13. Phone No. (Area/Country
/City Code, Number, Ext). 01480 302700 14. Internet email address rowan.beale@42technology.com Product details 15. Equipment model P2100005 16. FCC ID Number GRANTEE CODE 17. FCC ID equipment code
(Max. 14 Chars.) 18. FCC ID Rule part. (15.249, 15.247, etc.) 2A2IY
-P2100005 Part 15C CSF410-TCB 6.0 Page 1 of 5 FORM CSF410-TCB FCC APPLICATION FORM 19. Type of grant Original Grant Class II Permissive Change Class III Permissive Change Change in ID (Provide original FCC ID number and grant date
(yyyy/mm/dd: ) 20. Seeking modular approval? Yes No 21. Contain a pre-approved radio module?
Yes No If yes, FCC ID of pre-approved module: 2AC7Z-ESPWROOM02 22. Are there provisions for using this radio within 20 cm of the head or torso? (belt clips, holster, headset, etc.) Yes No Other information 23. Do you wish to hold some information permanently confidential?
24. Do you wish to hold some information confidential short-term?
Notes or comments Free field Yes No Yes No CSF410-TCB 6.0 Page 2 of 5 FORM CSF410-TCB FCC APPLICATION FORM FCC application and signature Read each certification carefully before answering and signing this application. WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND/OR 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). 25. 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 authorized agent so certify?
Yes No 26. NOT PREVIOUSLY SUBMITTED NOR DENIED I certify that this product has not been previously submitted to the FCC nor to another TCB for certification. I further certify that this product has not previously been dismissed nor denied by the FCC nor by another TCB. 27. APPLICANT/AGENT ATTESTATION 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 issued by the TCB 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 FCCs technical requirements. Authorizing an agent to sign this application, is done solely at the applicants 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 TCB reserves the right to contact the applicant directly at any time. 28. IEC/ISO 17065 REQUIREMENTS By signing this application, the applicant agrees to the following requirements and conditions:
a. The applicant will always comply with the relevant provisions of the certification programme, and the requirements of the regulatory body under which certification is granted, including implementing appropriate changes when they are communicated by the Element Certification Body. If the certification applies to ongoing production, the certified product continues to fulfil the product requirements. b. c. The applicant will make all necessary arrangements for:
i) ii) iii) the conduct of the evaluation, including provision for examining documentation and records and access to and access to the relevant equipment, location(s), area(s), personnel, and applicant's subcontractors;
investigation of complaints;
the participation of observers, if applicable. d. The applicant makes claims regarding certification consistent with the scope of certification. e. The applicant will not use its product certification in such a manner as to bring the Element Certification Body into f. g. h. i. j. disrepute and will not make any statement regarding its product certifications, which the Element Certification Body may consider misleading or unauthorized. The applicant will, upon suspension, withdrawal, or termination of certification, discontinue its use of all advertising matter that contains any reference thereto and takes action as required by the certification scheme (e.g. the return of certification documents) and takes any other required measure If the applicant provides copies of the certification documents to others, the documents shall be reproduced in their entirety or as specified in the certification scheme. In making reference to its product certification in communication media such as documents, brochures or advertising, the applicant will comply with the requirements of The Element Certification Body or as specified by the certification scheme. The applicant will comply with any requirements that may be prescribed in the certification scheme relating to the use of marks of conformity, and on information related to the product Applicant is required to maintain a record of all complaints made known to Applicant that relate to the compliance of the device described in this application with the requirements of the relevant standards for certification. Applicant will make such records available to the Element Certification Body upon request. In addition, Applicant is required to take appropriate actions with respect to such complaints and any deficiencies found in the device pursuant to such complaints and to document any corrective action taken. k. The applicant will inform the Element Certification Body, without delay, of changes that may affect its ability to conform l. to the certification requirements. The certification body at Element is self-funding from the certificates that it issues. Element maintains adequate arrangements (e.g. insurance or reserves) to cover liabilities arising from its operations, and has the financial stability and resources required for its operations. Fees for certification activities are applied on a project by project basis according to established fee schedules. Certification fees vary with the complexity of the project. m. Applicant will pay all fees in association with the application and ongoing certification activities such as surveillance and product modification;
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