1. 1.

   Subsystem/safety component or subsystem/safety component model (product, type, batch, or serial number):

2. 2.

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

3. 3.

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

4. 4.

   Object of the declaration (identification of the subsystem or safety component allowing traceability. It may, where necessary for the identification of the subsystem or safety component, include an image):

   • description of the subsystem or safety component,

   • all relevant provisions with which the safety component must comply and, in particular, the conditions of use.

5. 5.

   F2...

6. 6.

   References to the F3relevant designated standards used or references to the other technical specifications in relation to which conformity is declared:

7. 7.

   The F4approved body … (name, address, number) … performed … (description of intervention) … and issued the certificate(s): … (details, including its date, and where appropriate, information on the duration and conditions of its validity).

8. 8.

   Additional information:

Signed for and on behalf of: …

(place and date of issue):

(name, function) (signature):