制造商:

（制造商的地址和名称）

Manufacturer:

（Name and address of manufacturer）

特此声明:

Hereby declare:

以下产品:

（产品标识）

Products indicated below: （product mark）

符合以下协会指令条例：
Compliance with following associations’ directive:

1.______________________________________________

2.______________________________________________

其他（Other）:____________________________________

此外，作为零部件，这些产品符合以下基本要求:
In addition, these products are compliance with following basic demands as spare part:

1.______________________________________________

2.______________________________________________

其他（Other）:____________________________________

附加信息：（随附由有资质的检测机构或出厂方出具的检测报告，报告有效期控制在2年以内）
Additional information: （please enclose test report that provided by qualified test institute or factory, and the term of validity within 2 years）

作为零部件，这些机器在设计上符合以下基本要求:
As spare part, these machines are compliance with following basic demands in design:

1.______________________________________________

2.______________________________________________

其他（Other）:____________________________________

上述机器只有在声明已组装成符合机器指令的机器后才能投入使用。
The above machines will put into use only after declaration that the machines have been assembled into the machines which compliance with machine directive.

认证标示年份:

Certificate Mark Time:

进口商签名(Importer’s Signature)

盖章(Stamp)

出厂方签名(Factory’s Signature)

盖章(Stamp)

标题(Title) ___________

日期(Date) ___________

日期(Date) ___________