| 1. |
Trade name or mark of the vehicle................................................................................................................................................................................................ |
| 2. |
Vehicle type....................................................................................................................................................................................................................................... |
| 3. |
Manufacturer's name and address................................................................................................................................................................................................. |
| 4. |
If applicable, name and address of manufacturer's representative........................................................................................................................................... |
| 5. |
Brief description of the vehicle type as regards the arrangement of foot controls and foot rest............................................................................................... |
| 6. |
Vehicle submitted for approval on................................................................................................................................................................................................. |
| 7. |
Technical service responsible for conducting approval tests................................................................................................................................................... |
| 8. |
Date of test report issued by that service..................................................................................................................................................................................... |
| 9. |
Number of test report issued by that service............................................................................................................................................................................... |
| 10. |
Approval granted/extended/refused/withdrawn 2/ .................................................................................................................................................................... |
| 11. |
Position of approval mark on the vehicle...................................................................................................................................................................................... |
| 12. |
Place.................................................................................................................................................................................................................................................... |
| 13. |
Date..................................................................................................................................................................................................................................................... |
| 14. |
Signature............................................................................................................................................................................................................................................ |
| |
The list of documents deposited with the Administrative Service which has granted approval is annexed to this communication and may be obtained on request. |