ANNEX IX EU DECLARATION OF CONFORMITY No … (1)

1. PPE (product, type, batch or serial number):

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

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

4. Object of the declaration (identification of PPE allowing traceability; where necessary for the identification of the PPE, a colour image of sufficient clarity may be included):

5. The object of the declaration described in point 4 is in conformity with the relevant Union harmonisation legislation: …

6. 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:

7. Where applicable, the notified body … (name, number) … performed the EU type-examination (Module B) and issued the EU type-examination certificate … (reference to that certificate).

8. Where applicable, the PPE is subject to the conformity assessment procedure … (either conformity to type based on internal production control plus supervised product checks at random intervals (Module C2) or conformity to type based on quality assurance of the production process (Module D)) … under surveillance of the notified body … (name, number).

9. Additional information:

Signed for and on behalf of: …

(place and date of issue):

(name, function) (signature):

(1)

It is optional for the manufacturer to assign a number to the declaration of conformity.