ANNEX VI

1. No … (unique identification of the EEE):

2. Name and address of the manufacturer or his authorised representative:

3. This declaration of conformity is issued under the sole responsibility of the manufacturer (or installer):

4. Object of the declaration (identification of EEE allowing traceability. It may include a photograph, where appropriate):

5. The object of the declaration described above is in conformity with Directive 2011/65/EU of the European Parliament and of the Council of 8 June 2011 on the restriction of the use of certain hazardous substances in electrical and electronic equipment ( *1 ):

6. Where applicable, references to the relevant harmonised standards used or references to the technical specifications in relation to which conformity is declared:

7. Additional information: