1. Trade name or mark of the vehicle: 
2. Vehicle type: 
3. Vehicle category: 
4. Manufacturer's name and address: 
5. If applicable, name and address of manufacturer's representative: 
6. Description of the vehicle:
6.1. REESS type:
6.1.1. The approval number of the REESS or descriptions of the REESS2
6.2. Working voltage:
6.3. Propulsion system (e.g. hybrid, electric):
7. Vehicle submitted for approval on: 
8. Technical Service responsible for conducting approval tests: 
9. Date of report issued by that Service: 
10. Number of report issued by that Service: 
11. Location of the approval mark: 
12. Reason(s) for extension of approval (if applicable)2: 
13. Approval granted/extended/refused/withdrawn2: 
14. Place: 
15. Date: 
16. Signature: 
17. The documents filed with the request for approval or extension may be obtained on request.
[1]: Distinguishing number of the country which has granted/extended/refused/withdrawn approval (see approval provisions in the Regulation).
[2]:  Strike out what does not apply. 		a0c0