Fcc Form 740 Sample – Fill Out and Use This PDF

Trade name is what the product sells as.

Part II :

1.If FCC ID is filled in FCC ID field of Part I, choose number 1 statement.

2.If FCC ID is not filled in FCC ID of Part I, shipper or importer must read all options and mark the appropriate one.

FEDERAL COMMUNCATIONS COMMISSION	Approved by OMB
Washington, D.C. 20554	3060-0059
	Expires 08-31-2003

STATEMENT REGARDING THE IMPORTATION OF RADIO FREQUENCY DEVICES CAPABLE OF

CAUSING HARMFUL INTERFERENCE

(Read instructions before completing form. Please type or print clearly in ink.)

Part I - All Blocks MUST Be Completed

Date of Entry

Entry Number

Port of Entry1

Harmonized Tariff Number2

Quantity of Item (not number of containers)3

10

Device Model/Type Name or #

Trade Name

FCC ID

Description of Equipment

Model# 1014BF

ABC INT

CJ6XXX3272WWW

Notebook PC with CD-ROM Drive

Manufacturer’s Name and Address

Consignee’s Name and Address

Importer’s Name and Address

Manufacturer: ABC Malaysia Inc.

XXX Chan

Happy Trading USA

17 Sunset street, Petaling Jaya,

Same as Consignee

200 West Grand Ave, Woodstock,

Malaysia

WI, 53000, USA

Printed or Typed Name of Importer or Consignee

Signature of Importer or Consignee

Date (Month/Day/Year)

XXX Wong

November 16, 2004

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

Part II - With Regard to the Importation of the Described Radio Frequency Device(s), I DECLARE THAT:

(Place an “X” in only one box)

1.The FCC has issued a grant of equipment authorization for the FCC ID listed 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 of the U.S. (See Instructions)

6.The described equipment is being imported 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.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.

2.Harmonized Tariff Number – Harmonized Tariff Schedule of the United States.

3.This quantity must be total number of items, not number of containers.

FCC Form 740

August 2000

Part I :

Complete all information except Date of Entry, Entry Number and Port of Entry. If HS code and/or FCC ID is/are unknown, leave it blank.

Most of US ports accept shipper's signature, therefore FedEx accepts shipper's signature.