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1. No … (unique identification of the product): [Give type, batch or serial number(s) as appropriate]

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

3. Name and address of the manufacturer (and his authorised representative, if applicable):

4. Object of the declaration (identification of product allowing traceability. It may include a photograph, where appropriate): [Give MED entry number and description (e.g. MED/1.11 Line-throwing appliances), current version of implementing act and model and brand names, etc., Product description as given for EC type examination certificate]

5. The object of the declaration described above is in conformity with Directive 2014/90/EU

6. References to the relevant performance requirements and test standards - specifying also year of issue, version, dates - in relation to which conformity is declared: [Typically references to IMO documents and IEC, ISO, EN standards given in the relevant item in the implementing act and the Notified Body’s EC type examination certificate]

7. The notified body/bodies [give name(s) and number(s)] performed a [as appropriate indicate the used modules: B+D, B+E, B+F, G] conformity assessment procedure and issued the certificate(s): …[Indicate the certificate numbers, validity of Modules D and E].

8. Additional Information - Application and / or limitations (if any), as specified in EC Type Examination Certificate (Module B or G): [ Any limitations on the acceptance or use of the product or specific requirements stipulated in the relevant section of SOLAS, MARPOL, LSA, etc. or any other condition of validity - such as life rafts height of stowage, ….. ].

9. Signature:

Signed for and on behalf of: …………………………………

(place and date of issue):

(name, function) (signature):

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