附件一：MRA CAB（驗證機構）指派申請書
(Annex A: Application for Designation of Certification Bodies for Conformity Assessment of Telecommunication Equipment)
本公司對貴會公布之「國內電信設備驗證機構指派作業須知」已充分瞭解，並清楚瞭解作為貴會指派之電信MRA符合性評鑑機構（驗證機構）應負的責任，本公司保證所屬驗證機構確實具有成為當事國驗證機構之能力並願意督促所屬驗證機構切實遵守相關規定並全力配合貴會之相關要求，如有違反，願接受貴會廢止指派之處置並負起全部責任，絕無異議。
此致
國家通訊傳播委員會
To: National Communications Commission
Our company had fully understood the requirements of the “Directions Governing Designation of Domestic Certification Bodies of Telecommunication Equipment” and the responsibilities as a CAB of MRA designated by National Communications Commission (NCC). Our company ensures that the applicant is capable of being a CAB relating to the designation to the MRA Party and all the rules and requirements associated with MRA CAB are being adhered to. If in violation of the terms, we accept the resolution for withdrawal of designation by NCC with no objection.

1.	申請人資料(Applicant Information)
申請人名稱：
Name of Applicant: 	
代表人姓名：
Name of Representative: 	
申請人地址：
Address of Applicant: 	
2.	驗證機構資料(Certification Body Information)
驗證機構名稱：
Name of Testing Lab:	
驗證機構地址：
Physical Address of Certification Body: 	
驗證機構郵寄地址：
Mailing Address of Certification Body:	
室外測試場地址（於必要時填列）：
Open Area Test Site’s Address (If applicable):	
網址（Web Site）: 	
驗證機構負責人(Head of Certification Body)
	姓名：
Name：	職稱：
Title：	
	電話(Tel): 	傳真(Fax): 	
	電子信箱(E-mail): 	聯絡地址(Contact’s Address):
	
驗證機構聯絡人
(Contact Person of Certification Body)	姓名：
Name： 	職稱：
Title：	
	電話(Tel): 	傳真(Fax):	
	電子信箱(E-mail): 	聯絡地址(Contact’s Address):

4.認證資訊(Accreditation Information)
認證機構名稱(Name of accreditation body)：	
認證機構地址(Address of accreditation body)：
	
認證證書號碼（依據 ISO/IEC 17025認證）
(Certificate Number of ISO/IEC 17025 accreditation)：
	認證證書號碼（依據 ISO/IEC Guide 65認證）：
(Certificate Number of ISO/IEC 65 accreditation)：
	
認證證書核發日期(Date of issue of accreditation)：
	認證證書核發日期(Date of issue of accreditation)：	
認證有效期限(Date of Expiry of Accreditation)：
	認證有效期限(Date of Expiry of Accreditation)：	
5.	申請指派之範圍(Scope of Designation Sought) （如空間不敷使用，請另頁填寫）
國別(Country)	設備種類(Product Type)	Applicable Technical specifications 	
		技術規範代碼(Code)	技術規範名稱(Name of technical specifications)	
			Indemnify the authority from and against all liabilities, 	
申請人全銜及蓋章：	代表人簽章：	
(Name and Signature of applicant)                                          (Signature of responsible person)
本申請案聯絡人(Contact person)：	Title:	
TEL:	Fax:	E-mail:	
申請日期(Date of application)：

備註(Note)：
一、	乙份申請書以填報一個國家（經濟體）之資料為限。
It is required that one application form is applicable only for one country (economy).
二、	當申請人之所有權或名稱異動時，應於二週內以新公司名稱檢具相關證明文件向本會重新提報。
The applicant who applies for CAB of MRA shall notify NCC with its new name of the company and submit related information in 2 weeks when changes are made to key information such as ownership or company name.