FEDERAL COMMUNCATIONS COMMISSION

Approved by MB

Washington. D.C. 20554 Expires

3060-0059 08-31-2003

STATEMENT REGARDING THE IMPORTATION OF RADIO FREQUENCY DEVICES CAPARLE OF CAUSING HARMFULINTERFERENCE
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Par I - All Blocks MUST Be Completed Date of Entry Port of Enry1 Entry Number

Harmonized Tariff Number2

Auw 31,20/1
Device Model/Type ame or #

AtwAftKj H 3
Trade ame FCCID

Quantlty of tem (not number of containers)3 R.S2H : <H <jniTS

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Description of Equipment
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Manufacturer's ame and Address

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Consignee's ame and Address

Importer's ame and Address .,

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(jbiqu-iTi -. 91 e.

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3,002)

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Printed or Typed ame of Importer or Consignee . / e r"P? T. UiA. Wl?/i

SiRnature of Importer or Consignee

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I Date (Month/Day/Year!

03/09/ZOll

Warning: Any person who knowingly makes a false declaration may be fned not more than $250,000 or imprsoned not more than 5 years, or both, pursuant to 18 U.S.C. 1001.

Part II - With Regard to thelrnportaton ofthe Described Radio Frequency Device(s), I DECLARE THAT:
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1. The FCC has issued a grant of equipment authorization for the FCC ID usted above. 2. An FCC grant of equipment authorization and an FCC ID are not required, but the equipment complies with FCC technical requirements. 3. The described equipment is being imported in limited quantities for testing and evaluation for compliance with technical requirements or marketing suitability. The equipment will not be offered for sale or otherwise marketed. (See Instructions) 4. The described equipment is being imported in limited quantities for demonstration at industry trade shows and will not be offered for sale or otherwise marketed. (See Instructions) 5. The described equipment is being imported solely for export. It will not be offered for sale or otherwise marketed in the U.S. 5(a). The described equipment is a non-U.S. standard cellular phone that can only function outside ofthe U.S. (See Instructions) 6. The described equipment is being impored for use exclusively by the U.S. Government. 7. Three or fewer radio receivers, computers, or other unintentional radiators as defined in Part 15 of the FCC Rules, are being imported for an individual's personal use and are not intended for sale. 8. The described equipment is being imported for repair and will not be offered for sale or otherwise marketed.
1. 2. 3. Port of Entry Use Schedule D - Classification of U.S. Customs Districts and Ports for U.S. Foreign Trade Statistics - a four digit code i.e., New York City. NY 1001. Harmonized Tariff Number - Harmonized Tariff Schedule of the United States. This quantity must be total number of tems, not number of containers.

FCC Forra 740

August 2000

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