CWSC Application - Wireless Broadband Alliance

Part 1 - Applicant

Company Name*

Type of membership*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of company*

Dedicated contact person*

Fax Number*

Telephone Number*

Email address*

Sponsor Manufacturer*

(If Yes – Please fill with Sponsor Manufacturer details)

Name of Company*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email address*

Designated Contact Person*

Part 2 - Testing

Services to be tested**

*Please check Annex 1 – PROFORMA for selecting specific features / options available for the selected certification(s)

Carrier Wi-Fi Roaming Services Certification
Carrier Wi-Fi Offload / AAA / Authentication Services Certification
Online Sign-up / Provisioning Services Certification

Select the official WBA Lab**

*For Request for Quotation from all the labs please information WBA PMO (notes section below)

Kyrio, Colorado US

Equipment submitted to the testing*

Please specify (other)*

Model Name*

Model Version*

Firmware version*

Notes

Part 3 - Certificate

(Only applicable when the applicant is a vendor/manufacturer member of WBA)

Certificate - Company Name*

(If different from the applicant Company Name)

Certificate Holder*

This is the person to whom the approval or certificate will be issued, this name would appear on the certificate (If different from the applicant Designated Contact person)

Address of Certificate Holder*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have any constraints with publishing the certificate on the program website as per the normal process (e.g. specific publication date)?*

Part 4 - Declaration and Electronic Signature

I, the undersigned, do hereby declare that the information provided in this application is correct and accurate to the best of my knowledge. If granted a certificate or approval, I agree to operate in accordance with the rules, procedures and conditions established for CWSC. I understand that a certificate issued for this type of terminal equipment is valid on the condition that the equipment to be used is identical to the one tested or described and that any changes to the name, model or type of equipment approved will require a new application for approval or certification. I also understand that the certificate or approval may be revoked if the terminal equipment is used outside of the scope of approval or has been obtained through the provision of false information or other illegal means.

Electronic Signature*

Date*