Division APPROVAL CERTIFICATEX1

Name of competent administration …

Notification concerning ^f1 :

• approval of a type of recording equipment

• withdrawal of approval of a type of recording equipment

• approval of a model record sheet

• withdrawal of approval of a model record sheet

Approval No:

….

1. 1..

   Trade mark or name …

2. 2..

   Name of type or model …

3. 3..

   Name of manufacturer …

4. 4..

   Address of manufacturer …

5. 5..

   Submitted for approval on …

6. 6..

   Tested at …

7. 7..

   Date and number of the test(s) …

8. 8..

   Date of approval …

9. 9..

   Date of withdrawal of approval …

10. 10..

    Type or types of recording equipment in which sheet is designed to be used

11. 11..

    Place …

12. 12..

    Date …

13. 13..

    Descriptive documents annexed …

14. 14..

    Remarks (including the position of seals if applicable)

(Signature)