Apparatus model/Product (product, type, batch or serial number):

Name and address of the manufacturer or his authorised representative:

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

Object of the declaration (identification of apparatus allowing traceability; it may include a colour image of sufficient clarity where necessary for the identification of the apparatus):

The object of the declaration described above is in conformity with the relevant Union harmonisation legislation:

References to the relevant harmonised standards used, including the date of the standard, or references to the other technical specifications, including the date of the specification, in relation to which conformity is declared:

Where applicable, the notified body … (name, number) performed … (description of intervention) and issued the certificate:

Signed for and on behalf of:

(place and date of issue):

(name, function) (signature):