(Tentative Translation)

Attached Table No.1
Form of Application for Technical Regulations Conformity Certification and Application for Certification for Each Equipment (Related to Articles 3 and 31) (If the Recognized Certification Body deems other forms to be substitutable for this form, such forms may be used)
Application for Technical Regulations Conformity Certification/
Certification for Each Equipment (Note 2)

(Note 1)

Date:           

To : The Minister of Posts and Telecommunications (Note 3)

ApplicantAddress (Note 4)                                             
 Name (Note 5)Seal

      I apply for Technical Regulations Conformity Certification/Certification for Each Equipment (Note 2) as follows, by submitting this application together with documents, etc. attached hereto in accordance with the provision of Article 3/ Article 31 (Note 2) of the Ordinance concerning Technical Regulations Conformity Certification of Specified Radio Equipment.

Description
Category of Specified Radio Equipment (Note 6)  
Type or Name of Applied Equipment  
Name of Manufacturer of Applied Equipment  
Serial Number of Applied Equipment (Note 7)  
Number of Pieces of Specified Radio Equipment  
Type, Frequency and Antenna Power of Radio Wave Applied for Certification of Conformity with Technical Regulations/ Certification for Each Equipment (Note 8)  
Remarks (Note 9)  
(JIS A4)
Short side
            
Notes
  1. In case of applying to the Minister of Posts and Telecommunications, a revenue stamp corresponding to the amount of fee shall be affixed.
  2. Cross out irrelevant letters.
  3. In case of applying to a Designated Certification Agency or a Recognized Certification Body, the addressee shall be the Designated Certification Agency or the Recognized Certification Body respectively.
  4. In case of a corporation or an organization, the location of its main office or principal place of business shall be entered.
  5. If written in the applicant's own hand, seal-impression may be omitted. In case of a corporation or an organization, its trade name or denomination, and title and full name of representative shall be entered, and a seal of the representative shall be impressed.
  6. 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" shall be made.
  7. No entry is required in the case where the Applied Equipment is not submitted.
  8. With regard to type, frequency and antenna power of radio wave (hereinafter referred to as "type, etc. of radio wave") applied for Technical Regulations Conformity Certification or certification for each equipment, all those involved shall be entered. Where there is the necessity for entering a variety of type, etc. of radio wave, an entry such as "F2D 903.0125MHz through 904.9875MHz (25kHz intervals 79 waves)" may be made, and a frequency band may be entered in case of an amateur station.
  9. In the case where the Applied Equipment is not submitted, an entry shall be made to the effect that the documents specified in the proviso of Article 3 or 31 are attached.