SECTION 1
(Must be completed in full)

Market Name of Product: .........................................................................................................................
[Max. of 40 characters see note]

Name of Manufacturer:..................................................

Country............................................

Formal Mfr's description/No:.......................................................................................................................

Ringer Number (RN) (Ref PTC 200 § 7.6): ..............................see note

Proposed Telepermit Holder Details: [Must be a New Zealand Company or Resident]

Telepermit Holder:..............................................................................................................................

Street Address:..................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Contact Person :.................................................

Position in Company :..............................................

Telephone:.................................... Fax:........................................

Mailing address [include PO Box number if available]:...........................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Date: ..................................................

For Telecom use only

Application Number: CP/AS............./ ...............

Application Received: (date) .........../ .........../ ............

Information Complete: (date) .........../ .........../ ............

Application Acknowledged: (date) .........../ .........../ ............

SECTION 2
Telepermit Applicant Details

(Where different to proposed Telepermit Holder)

Complete this section ONLY if a Company or agent is handling the application on behalf of proposed Telepermit Holder.

(Note that Declaration in Section 1 MUST be signed by the proposed Telepermit Holder)

Applicant: ........................................................................................................................................

Street Address: ...............................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Postal Address: .................................................................................................................................

[include PO Box number if available]

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Contact Person:..................................................Position in Company: ...............................................

Telephone:...................................... Fax:..........................................
Email:................................................

Billing Address (State Telecom Account Number if known): .................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Contact Person:..................................................Position in Company: ...............................................

Telephone:......................................

In all cases, this Application Form when completed should be forwarded directly to:-

Mail	Parcels
Access Standards Telecom New Zealand Level G, Unit 4, Telecom Centre PO Box 570 WELLINGTON 6140 NEW ZEALAND	Access Standards Telecom New Zealand Level G, Unit 4, Telecom Centre 49 - 55 Tory Street WELLINGTON 6011 NEW ZEALAND

Enquiries:-

General and Technical enquiries on Telepermit applications etc. should be directed to:-
Alan Reedy	Tel: +64-4-382 1546	Fax: +64-4-801 5691	E-mail: alan.reedy@telecom.co.nz
Richard Brent	Tel: +64-4-382 5344	Fax: +64-4-801 5691	E-mail: richard.brent@telecom.co.nz

NOTES
1. Reserved Telepermit Numbers are issued so that manufacturers can arrange to have labels printed in parallel with the approval process. It is expected that the Testing will have already been completed, or at least substantially completed when a Reserved Number is applied for. Reserved numbers will expire two months after the date of issue, and be reallocated to other products unless an extension of time is granted.

There is no guarantee that a Telepermit will be granted, and product must not be sold before the appropriate Test Reports have been assessed and a Telepermit has been formally granted. An artwork is provided to assist with the production of Labels.

2. As labels for all equipment connected to the PSTN (PTC 200)contain the Ringer Number (RN) for the equipment, this must be provided as part of this application. The RN is found in Test Reports to PTC 200 clause 7.6.

3. The Market name of the product will be printed on the Telepermit Label and must match the name printed on the product itself and the product documentation. The form of this entry is: Brand Name, Product Name (i.e. model), Product Class (e.g. facsimile machine, telephone etc) Note that each individual product name must have a separate application, Telepermits are not issued to a product family.

4. This Section is required to be completed in full. A Reserved Number will NOT be issued until Section 1 has been fully completed.

SECTION 2
A company or person other than the eventual Telepermit Holder may deal with the application process. However, the Declaration in Section 1 must be signed by the proposed Telepermit Holder, who is in turn responsible for the General Conditions of Telecom Specification PTC100, and also for any special condtions associated with the particular product.

Fees: The fee for a Telepermit Reservation is $NZ524.25 (including GST for NZ companies) and is charged at the time of issue of the Reserved Telepermit Number. This covers the Reservation and the normal assessment fee for the Telepermit grant. If the assessment subsequently turns out to more complex, further charges may be levied at that time. Note that there is a charge of $NZ130.50 (inc) for any change of name after the label is first produced.