Vessel/vessel model (product, type, batch or serial number):

Name and address of the manufacturer and, where applicable, his authorised representative:

This declaration of conformity is issued under the sole responsibility of the manufacturer.

Object of the declaration (identification of the vessel allowing traceability; it may, where necessary for the identification of the vessel, include an image):

The object of the declaration described above is in conformity with the relevant F4statutory requirements:

References to the relevant F3designated standards used or references to the other technical specifications in relation to which conformity is declared:

The F2approved body  (name, number) performed  (description of intervention) and issued the certificate:

Additional information:

Signed for and on behalf of: (place and date of issue): (name, function) (signature):