Instrument model/Instrument (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 instrument allowing traceability; it may, where necessary for the identification of the instrument, include an image):

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

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

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):