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S U P P L I E R ÷ S D E C L A R A T I O N O F C O N F O R M I T Y S e c t i o n 1 3 4 ( 1 ) ( g ) o f t h e N e w Z e a l a n d R a d i o c o m m u n i c a t i o n s A c t 1 9 8 9 S e c t i o n 1 8 2 o f t h e A u s t r a l i a n R a d i o c o m m u n i c a t i o n s A c t 1 9 9 2 THIS COMPLETED FORM REMAINS WITH THE SUPPLIER AS PART OF THE DOCUMENTATION REQUIRED FOR THE “COMPLIANCE FOLDER” A SUPPLIER DETAILS Name: (of manufacturer, importer or authorised agent) Physical address: Contact information: Postal address: (if different) Telephone: Mobile: Fax: E-mail: (New Zealand) Company number or GST Number (Australia) ©, ARBN or ABN: Supplier Code Number: (include “Z” or “N”) B PRODUCT DETAILS Brand name: Model, lot, batch or serial number: Description and function: If radio product: Frequency: Radiated power: e.i.r.p (W) Applicable standard title, number and edition: Test report number: C DECLARATION: I hereby declare that the product mentioned above complies with the above mentioned standard, and all products supplied under this declaration will be identical to the sample identified above. Signature of supplier/agent: Print name: Date: Position in organisation: TomTom C/O Nigel Arkell Chartered Accountants Level-3, 34 Shortland St. Auckland 1010 P.O. Box 164 Shortland St. Auckland 1140 +61 2 9490 3616 +61 2 98898856 [email protected] 2105694 Z1230 TomTom GPS, Bluetooth 1575MHz, 2402-2480MHz AS/NZS 4268:2012 (EN300328 v1.7.1 ), AS/NZS CISPR22:2009 Vince Wolfe VP Product Development 4FA50, 4FB40, 4FA60 and accessories. +A1:2010 Jun. 6th , 2013 ER332116, ER332123, ER332118. EW332116 , EW332123, EW332118 . 1.33dBm, 2.06dBm, 1.87dBm
