Admission Application Forms
LTE Immunity Certification
 
Instructions
A completed and signed registration form MUST be sent by e-mail to testing@excentis.com (scanned version)
Part 1a: General Information
Manufacturer:
Product Name:
Product Type: CM - EMTA - EDVA - STB - STB/CM - STB/EMTA - STB/EDVA
Product is submitted into a LTE Immunity Certification Run.
Product is submitted to test against an E-Field of 5 V/m (accepted E-field values are 3, 4, 5, 6, 7, 8, 9, 10 V/m).
The undersigned agrees with the terms and conditions written in the applicable guidelines (available on the Excentis website).
Product Manager:
Name:
Title:
E-mail:
Address:
Telephone:
Fax:
Date: Signature:
Financial Dep. Contact:
E-mail:
Address for Invoice:
Fax for Invoice:
VAT ID (EU companies):
PO number (if required):
Legal Dep. Contact:
E-mail:
Address:
Telephone:
Fax:
Technical contact(s):
E-Mail:
Telephone:
Part 1b: General Information
Manufacturer:
Product Name:
Shipping rules
All shipments from and to Excentis and related to this project are at the cost of the vendor, including all customs, tax and handling charges. Any such costs must be charged at the account number of the vendor mentioned below.
This applies to all shipments from and to the vendor, and related to this certification test run.
I hereby declare that our company is responsible for all the customs, tax and handling charges. All the costs from and to Excentis can be charged on the account number mentioned below.
Name:
Function:
Date:
Signature:.................................................
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Shipment Company:
Vendor account nr:
Vendor contact for shipments:
E-Mail:
Telephone:
Return address:
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Part 2: Detailed Product Information
Manufacturer
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Product Name
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Hardware Revision
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Software Revision
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Silicon source and type
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Supported Wi-Fi bands: NA / 2.4 GHz /2.4 and 5 GHz
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Wi-Fi Dual band concurrent: yes/no
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MAC addresses of the submitted devices:
Sample number
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CM MAC
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MTA/DVA MAC
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STB MAC
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Serial Number
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01
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02
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03
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This Admission Application and other documentation are being submitted to Excentis for use in granting certification for the product described in the “Product Information” section. The applicant (i) acknowledges that this information will be used and relied upon to grant certification, and (ii) certifies that:
The test results accompanying this application have been gathered using the product configuration described in the “Product Information” section of this application.
The information contained in this application, the supporting test results and other documentation supplied with this application are true and correct.
The applicant has satisfied all material requests and all of the requirements on its part to be certified as compliant with the specifications applicable for this certification test program..
Corporate Officer:
Title:
E-mail:
Address:
Telephone:
Fax:
Date: Signature:
Quality Ass. Manager:
Title:
E-mail:
Address:
Telephone:
Fax:
Date: Signature:
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