Telecom Terminal Equipment Sample Recovery Form

The Hashemite Kingdom of Jordan Telecommunications Regulatory Commission ‫ﻫﻴﺌــﺔ ﺘﻨﻅﻴــﻡ ﻗﻁــﺎﻉ ﺍﻻﺘﺼــﺎﻻﺕ‬ ‫ﺍﻟﻤﻤﻠﻜﺔ ﺍﻻﺭﺩﻨﻴــﺔ ﺍﻟﻬﺎﺸﻤﻴــﺔ‬ (Form# STA1-4, rev.1) Telecom Terminal Equipment Sample Recovery Form Date: ………………………………… Recipient Name: …………………………………...………………………………….………….. Representative of Company/ Custom ………………………………………………………. I have received the samples mentioned below which previously submitted to the Telecommunication regulatory Commission for testing purposes according to the commission in notice # …………………. Date …………….. Equipment Name 1 2 3 4 5 6 7 8 9 Brand Model Quantity Country of Origin Recipient Identity Signature 1/9/2004 1/1