(referred to in Article 44)
1. No … (unique identification of the product):
2. Name and address of the manufacturer and, where applicable, the manufacturer’s authorised representative:
3. This declaration of conformity is issued under the sole responsibility of the manufacturer:
4. Object of the declaration (description of the product sufficient for its unambiguous identification and allowing traceability; it may, where necessary for the identification of the product, include an image):
5. The object of the declaration referred to in point (4) is in conformity with this Regulation, the delegated act adopted pursuant to Article 4 and, where applicable, other Union harmonisation legislation:
6. References to the relevant harmonised standards or to the common specifications used or references to the other technical specifications in relation to which conformity is declared:
7. Where applicable, the notified body … (name, number) performed … (description of intervention) and issued the certificate or approval decision … (number):
8. Where appropriate, the reference to other Union law providing for the affixing of the CE mark that is applied:
9. The identification and signature of the person empowered to bind the manufacturer or the manufacturer’s authorised representative:
10. Additional information:
Signed for and on behalf of:
(place and date of issue):
(name, function) (signature):