ANNEX IVSupplementary provisions
ANNEX IV Model for the EU type-approval certificate concerning driving licences which include a microchip Name of the competent authority: … Notification concerning ( 1 ) : — approval — withdrawal of approval of an EU Driving Licence including a microchip Approval No: … 1. Manufacturing brand or trademark: … 2. Name of model: … 3. Name of manufacturer or of its representative, where applicable: … … 4. Address of manufacturer or of its representative, where applicable: … … 5. Laboratory test reports: 5.1 Security Certificate No: … Date: … Issued by: … 5.2 Functional Certificate No: … Date: … Issued by: … 6. Date of approval: … 7. Date of withdrawal of approval: … 8. Place: … 9. Date: … 10. Descriptive documents in Annex: … 11. Signature: … ( 1 ) Tick the relevant box.