1053 South 1675 West, Orem UT 84058 800-494-1778, 801-705-3464 FAX FM Transmitter Certification Form To: Lynda Company:

HobbyTron.com Fax: 1-801-705-3464 Date: Subject: FM-TRANSMITTER This form is used to verify that your purchase of a FM TRANSMITTER product(s) wi ll be used in accordance with appropriate laws regulating intentional radiators. Please provide the following information to allow your order to be processed wi thout delay. I hereby certify that the product(s) will be operated in accordance with applica ble laws of the land for the intended destination of operation. If resold, we ad ditionally certify that we will f\enforce this compliance to the purchaser. I do understand that the product(s) may exceed the legal limits set by the FCC and m ay not be authorized to be used in the USA. If for any reason I am notified that I am interfering with the signal of anyone else, I agree to terminate my transm ission to prevent any further interference. In any case, Gibson Tech Ed, Inc. or HobbyTron.com will not be responsible for m y use of this product, and it is my sole responsibility to now and obey the app licable laws. You further agree to defend, indemnify, and hold harmless Gibson T ech Ed, Inc. (dba Hobbytron.com) from any claims actions or demands resulting fr om improper use of this equipment. Purchaser: ________________________________________________________ End User OR (Person or Company Name) Dealer/Reseller Billing Address: ____________________________________________________ __________________________________________________________________ __________________________________________________________________ Printed Name: ______________________________________________________ (If different than Purchaser above) Signature: _________________________________________________________ Title: ______________________________________________________________ Date: ______________________________________________________________