EFTA01221150.pdf

Commercial Invoice INTERNATIONAL NOTE: All abiptrccts must be accgrapatticd by AIR WAYBILL NO. a FedEx International Mr waybitL DATE OF EXPORTATION EXPORT REFERENCES ;i.e. order no.. Holt:cc no.. etc) SHIPPER/EXPORTER (complete name acid adduct) CONSIGNEE (con:plcic Da= and address) COUNTRY OF EXPORT IMPORTER - IF OTHER THAN CONSIGNEE (complete new end address) COUNTRY OF MANUFACTURE COUNTRY OF ULTIMATE DESTINATION NO. OF TYPE OF FULL DESCRIPTION OF GOODS QTY. UNIT OF WEIGHT UNIT VALUE TOTAL PIGS. PKCi. MEASURE VALUE TOTAL TOTAL TOTAL PKGS. WEIGHT INVOICE VALUE CHECK ONE C&F C I.F. THESE COMMODITIES. TECHNOLOGY. OR SOFTWARE WERE EXPORTED FROM THE UNITED STATES IN ACCOR- DANCE WITH THE EXPORT ADMINISTRATION REGULATIONS. DIVERSION CONTRARY TO US. LAW PROHIBITED. I W.:de:LABE ALL THH INFORMATION CONTAINED IN THIS IN VOICE TO BE TRUE AND CORRECT. SIGNATURE. OF SHIPPER/FJC PORTER DATE EFTA01221150 FEDERAL CONAtudICATiONS COMMiS S ION Cl.- EO72/tP7 Approved by OME 3060.0050 Expires 05-31.2003 Washington, D C. 20554 STATEMENT REGARDING THE IMPORTATION OF RADIO FREQUENCY DEVICES CAPABLE OF CAUSING HARMFUL INTERFERENCE moo inSINCSOns ben compArtitg tern amens,if pant Warty a ink) Part I - All Mocks MUST Be Completed Dale of Entry Entry Number Port of Ent) I Karmonized Tariff Numb( 2 Quantity ti Item (nOt number of container Device kkdoirType Name or U Trade Name FCC ID Description of Equipment Manuiacturer's Name and Address Consignee's Name and Address Importer's Marne and Address Nave .• Ilene .• Nave patient : Itikkent Adiesel : Adenss2 : Address2 Aikess2 : Beta* : Beene Data : StateCaN : SteleCale Stalest ewer, : Country Peenry Pnnted or Typed Name of Importer a Consignee Signature of Importer o Consignee Date (Matti/030Year) Wanting: Any person who knowingly makes a false declaration may be fined not more than 5250.000 or imprisoned not more than 5 years, o both, pursuant to 18 U.S.C. §1001. Pan 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 di& FCC ID listed above. 2. An FCC grant of equipment authorization and an FCC ID am not required. bin the equipment comphes with FCC technical requirements. 3. The [ascribed equipment Is being imported in United quantitate fOr leering and eVilbJatiOn fOr compliance with !ethnical regteernente or marketing Suitabtity. 7 equipment will not be offered for sate or otherwise marketed. (See Instructions) 4. The described equipment is being imported in limited quarideS tor demonstrabon at industry trade shows and will not to offered for sale or olhenvise narkete (See listructions) 5. The cescribed equipment is being imported solely for export It we 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 Oescnhed equipment is being rimmed for use exclusively by the U.S. Government. 7. Three or fewer radio receiver. Computers. Or other unintenaonal radiators as defined in Pert 15 of the FCC Rules, are being Weeded for an individual's peace use and are not intended for sale. 6. The described equipment Is being everted for repair and wit not be offered for sale or °tennis* marketed. 1. Port Entry Use Schedule 0 Classification of U S Customs Detects and Ports for U S. Foreign Trade Sialishcs • a Sour Mal cotie i e.,New Yak City. NY 100i. 2. Harmonized Tariff Number • harmonized TaM Schedule ti the WM SRNs. J. MN quantity must be total number of mere nor numeer of containers. FCC Form 74D August 2300 EFTA01221151  A-4/7 oapAR- WEN7 OF X£AL7.-1. E.7JCATION.mo WELFAR°. I ra= A*=..,:r4 "WE 57.1r • 20 70../5-:JC:-7:14.7.- SERVICE pfISMUCT.ONS- FOOD AND OftuS tADMINtSTPATION 1. irpe or:p:inl ult.. bat poll:: can DECLARATION FOR PRODUCTS SUBJECT TO 2. &Graft ons copy rip U.S. Cameos S W.= :Stay Rapes RADIATION CONTROL STANDARDS (11113.Mr tot =*-.t IO F=ra FO 701. *TT,.=Ior Erare Notice.' . DISTRICT! PORT OIR.ECTOR CF CUSTOMS IPORT OF ENTRY !EMMY NO. IC1Ari if PRODUCT ICENTWICATION NAME AND ADORE° S DR yANUFAC7UPER INAME ANC ADSRESS IMPORTER O RECORD [X LIS TiMATE t OftSED.EE [ OtJANTirl !TYPE ERANC NAME ;MODEL NO. FOR X-RAY. L1S7 APPRDP;ATE SYS'17..4.8S OR CC.Ie.ONer CATEGORY i AlFiRWMON (Check aocrociate statement and sign.) Me hereby declare: A. That the eiectroac produtts identified above were manufactured ;nor :o the Cate of any ilpidable ety.otronlc product petorrnance standard Date of m.itnufact..:re - a. that the electronic pr ducts derled aeon comply with-n performance sWidards ores.—abed in Food and ON; Administration Rules 21 C.4--R 1010 which are appiieb.% at the date cf icanuf-ture and that a cerdfi=e in the form of a tag or Label to thil effect is affixed tc each product. !- C. That the 'Ay:Tonic. pr u= icinentifted above do not comply yeah the. petmance — standards presclbed in the Food and Drag Administration Rules 21 CFR 1010 but age being Lmported icr the pt:7-cse of research. irreesagations,stodies demonstraSors, of trainBr,g. An asempeon for these croducts nes been or will be. requested of the Director of the FDA Sweat) of Radiological ikaith and Woe/ Act Troy w not be introduced into "commerce, and when: their rSsion is completed they.wid be desmyed or exported under United States Customs Se.rtioe Sucaraion. !I D. That the etectonim prodtcis above Cr not =mote with the perfOrnance — standards oreicted in the Food and Ein.:g Administration Rules 21 CFR 1010 but that a dineiy and adequate ;sedan for permission ao bring the product hto compliance with i'1=amicable standards has been or wig with the Food And Drag Administration in accordance with 21 CFR 1005.21. These p:oducts %Pi! remain under bond apCwili no! ee introduced into commerce untiP asdfith:)n s reaeved from tie Food and Dray Administration, that the produes are in cmpiarice with aopiicab4 sta4ards. Signature of 4-r.perter of Record tra'S:n15 EFTA01221152