Annex X

1.

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

5.

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

6.

References to the relevant harmonised standards 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:

8.

Additional information: Signed for and on behalf of: (place and date of issue): (name, function) (signature):