Application for Equipment Authorization FCC Form 731 TCB Version
Applicant's complete, legal business name:
Samsung Electronics Co Ltd
FCC Registration Number (FRN):
Alphanumeric FCC ID:
Unique Application Identifier:
19 Chapin Rd., Building D
TCB Application Email Address:
A1: Low Power Transmitters below 1 GHz (except Spread Spectrum), Unintentional Radiators, EAS (Part 11) & Consumer ISM devices
Person at the applicant's address to receive grant or for contact
Chan Ho Youn
SGS Korea Co., Ltd.
4, LS-ro, 182 beon-gil
Non Technical Contact
SGS Korea Co., Ltd.
4, LS-ro, 182 beon-gil
Does this application include a request for confidentiality for any portion(s) of the data
contained in this application pursuant to 47 CFR § 0.459 of the Commission Rules?:
Does short-term confidentiality apply to this application?:
If so, specify the short-term confidentiality release date (MM/DD/YYYY format):
Note: If no date is supplied, the release date will be set to 45 calendar days past the date of grant.
Software Defined/Cognitive Radio
Is this application for software defined/cognitive radio authorization?
DXT - Part 15 Low Power Transceiver, Rx Verified
Description of product as it is marketed:
(NOTE: This text will appear below the equipment class on the grant):
LED View Cover
Related OET KnowledgeDataBase Inquiry
Is there a KDB inquiry associated with this application?
Does not apply
Application is for:
Is the equipment in this application a composite device subject to an
additional equipment authorization?
Is the equipment in this application part of a system
that operates with, or is marketed with, another device that requires an equipment authorization?
Test Firm Information
Name of test firm and contact person on file with the FCC:
Enter any text that you would like to appear at the bottom of the Grant of Equipment Authorization:
The implementation of this sleeve supports only the phone models authorized under FCC ID: A3LSMG960U. Transmissions are limited to authentication and NFC operations.
Set the grant of this application to be deferred to a specified date:
Equipment Authorization Waiver
Is there an equipment authorization waiver associated with this application?
If there is an equipment authorization waiver associated with this application, has the associated waiver been approved and all information uploaded?:
WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND IMPRISONMENT
(U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR
CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1)), AND/OR FORFEITURE
(U.S. CODE, TITLE 47, SECTION 503).
SECTION 5301 (ANTI-DRUG ABUSE) CERTIFICATION:
The applicant must certify that neither the applicant nor any party to the application
is subject to a denial of Federal benefits, that include FCC benefits, pursuant to
Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. § 862 because of a conviction
for possession or distribution of a controlled substance. See 47 CFR 1.2002(b) for the
definition of a "party" for these purposes.
Does the applicant or authorized agent so certify?
I certify that I am authorized to sign this application. All of the statements herein and the
exhibits attached hereto, are true and correct to the best of my knowledge and belief.
In accepting a Grant of Equipment Authorization as a result of the representations made in this
application, the applicant is responsible for (1) labeling the equipment with the exact FCC ID
specified in this application, (2) compliance statement labeling pursuant to the
applicable rules, and (3) compliance of the equipment with the applicable technical rules.
If the applicant is not the actual manufacturer of the equipment, appropriate arrangements
have been made with the manufacturer to ensure that production units of this equipment
will continue to comply with the FCC's technical requirements.
Authorizing an agent to sign this application, is done solely at the applicant's discretion;
however, the applicant remains responsible for all statements in this application.
If an agent has signed this application on behalf of the applicant, a written letter of
authorization which includes information to enable the agent to respond to the above section
5301 (Anti-Drug Abuse) Certification statement has been provided by the applicant.
It is understood that the letter of authorization must be submitted to the FCC upon request,
and that the FCC reserves the right to contact the applicant directly at any time.
Signature of Authorized Person Filing:
Title of authorized signature: