(Tentative Translation)

Attached Table No.4
Form of Certificate of Conformity with Technical Regulations and Certificate for Each Equipment (Related to Articles 5 and 33) (If the Recongized Foreign Certification Body deems other forms to be substitutable for this form, such forms may be used)
Certificate of Conformity with Technical Regulations
Certificate for Each Equipment Note 1)
Category of Specified Radio Equipment (Note 2)  
Type, Frequency and Antenna Power of Radio Wave  
Type or Name  
Name of Manufacturer  
Serial Number  
Number of Technical Regulations Conformity Certification/
Certification for Each Equipment (Note 1)		  
Date of Technical Regulations Conformity Certification/
Certification for Each Equipment (Note 1)		  

I hereby certify that Technical Regulations Conformity Certification/Certification for Each Equipment (Note 1) has been granted as above in accordance with the provision of Paragraph 4 of Article 38-2/ Paragraph 1 of Article 38-17 (Note 1) of the Radio Law.

Date  
The Minister of Posts and Telecommunications (Note 3) Seal
 
Short side
(JIS A4)
Notes:
  1. Cross out irrelvant letters.
  2. According to the categories of designation mentioned in each Item of Article 8, an entry such as "The radio equipment mentioned in Item __ of Article 8 of the Regulations for Specified Radio Equipment Certification of Conformity with Technical Regulations" shall be made.
  3. In the case where a Designated Certification Agency has granted the Technical Regulations Conformity Certification, name of the Designated Certification Agency shall be entered, and in the case where a Recognized Certification Body has granted the certification for each equipment, name of the Recognized Certification Body shall be entered.