relevant certificate no.
Applicant/certificate holder (company):
Product designation: Type:
Classification of the planned changes: ☐ Extension of the scope to the above-mentioned certificates without extension of the term due to: ☐ Addition of types / options ☐ others: Explanation / Description:
☐ modification to the above certificates without extension of the term due to: ☐ editorial changes (company name, product renaming, ...) ☐ Changes to the product ☐ Changes to the production process / change of production site ☐ Changes to the documentation, in particular the user information ☐ Other changes: Explanation / description:
Intended implementation of modifications ☐ from the date ☐ with serial number (S/N) ☐ lot number ☐ batch number

☐ There are enclosures to this declaration

,

____________	______________________	_________________________

Place, date	Signature	Capacity within the company

Please return the completed document as PDF to: pz-hm.fbhm@bghm.de.

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