RSP-100, Form A — Application and Agreement for Certification Services

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Company name:		Contact name:
ISED company number:		Telephone:
Company address:		Fax:
Company address:		Email:

Company name:		Contact name:
ISED company number:		Telelphone:
Company address:		Fax:
Company address:		Email:

Product description:		ISED certification number:
PMN:		FVIN:
HVIN:
RSS(s) and issue #
Type of certification service:	New single certification New family certification Existing family (C1PC) Modifications (C2PC, C3PC, C4PC) Multiple listing Full transfer of TAC Partial transfer of TAC	HMN:	MA LMA

Payment amount ($):		Payment method:	Cheque Credit card
Cardholder / Payment by:	Applicant Representative	Credit card type:	Visa MC AMEX
Name on the card:		Card number:
I agree to pay the total amount stated above in accordance with the credit cardholder's agreement.
Cardholder signature:		Card expiry date:

The Applicant agrees to: accept responsibility for all departmental charges arising from this application meet all requirements in accordance with Radio Standards Procedure RSP-100 and other applicable procedures warrant that the test results submitted are a true representation of the characteristics of the radio equipment type for which certification is requested inform ISED of any changes to the information submitted
Contact name: Applicant or Authorized agent		Contact person title and company name:
Signature:		Signature date:

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RSP-100, Form A — Application and Agreement for Certification Services

Notice