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APPLICATION FOR THE ISSUE OF ACMA CB STATEMENT
AND TELECOM CERTIFICATION / MODIFICATION

Electrical Product Safety Certification Scheme (EPSCS)

Section 376 Section Technical standards & 407 Section Labelling Requirements of
Telecommunication Act 1997

Please complete and confirm details below to appear in the ACMA CB Statement
and the CBA Telecom Certificate of Compliance

Select services required:
 NEW APPLICATION MODIFICATION RENEWAL
ACMA CB Statement/Certificate of Approval Holder Details:
Registered Company Name:
ABN (if applicable):
Mailing Address:
Contact Person:
Telephone No.:
Email:
Agent Details (if applicable) - please submit Agent’s Authorisation:
Agent Name:
Mailing Address
Contact for Enquiries:
Telephone No.
Email
Manufacturer Details:
Manufacturer Name & Address (if different from the certificate holder)
Factory Name & Address (if different from the certificate
Product Information:
Product:
Trade Mark:
Model No.:
Software Version:
Hardware Version:
Rated Voltage:
Rated Frequency:
Rated Power:
Other marking:
Test Reports:
Test laboratory/
Recognised testing authority		 Listing # Report # Date Standard
Non-compliance issues:
Do you agree to the Certification Body discussing network integrity issues with carriers or carriage service providers?  yes
Tick applicable box. *  no
Modification and Renewal Application Details:
Original Certificate Number:
Date of Issue:
Original Model No.:
Indicate changes in the design, material or construction from the original approved product:

NOTES TO THE APPLICANT

1. Submission of an application and payment does not require the certification body to issue a certificate that the customer equipment or customer cabling complies with the standards where it does not in the opinion of the certification body.
2. The maximum processing time for a complete application is 20 working days subject to carrier clearance (if applicable).
3. The applicant may request a stop of work on the application at any time. In this case, the application will be returned but the payment will be retained.

Checklist for documentation required:

 Accredited test reports and certificates (to show compliance)…………………………
 Instruction manuals, rating labels, warnings (English language only)…………………
 Colour photographs, certification for critical components ……………………
 Agent’s authorisation (if applicable)……………………………………….

TEST SAMPLE WILL BE REQUIRED

DECLARATION by
ACMA CB Statement/Certificate of Approval Holder:


I hereby declare that:
(a) The contents of this application and any enclosures are true and correct; and
(b) I have the authority to sign this application on behalf of the applicant.
(c) That I did not apply this device for approval with other ACMA Certification Body
Each article described above complies with the standards nominated.
Each article of the description specified above for which approval is hereby sought, is identical to the electrical article being the subject of the test reports attached.
Any modification to components, construction or design of the article will be notified to Certification Body Australia.
I agree and comply with the obligations set out in the CBA Terms and Condition for certification services.

Signature: * I confirm my declaration above

 Yes No

Print Name:
Title:
Certification Fees (excl. GST) – all prices in Australian dollars
New certificate application (Australian telecom approval): $ 3,200.00 (voice device)

$ 2,800.00 (data only device)
Certificate Addendum (simple technical change): 600.00
Certificate Renewal: 750.00
Certificate Modification (non-technical change): 350.00

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