自行管制聲明書

Declaration of Internal-Control

本申請人切結保證經貴局審查核可之驗證登錄自行管制模式（模式一）商品，必採各項品質管理措施，並確保所同意登錄之商品於生產時符合貴局公告指定標準及相關技術規範，絕無不符本保證事項。商品資料如下：

I hereby declare that the products described below registered under the BSMI’s Registration of Product Certification Scheme by following the Internal-Control Module are subject to the necessary quality management measures, and assure that they are in conformity with the requirements of designated standards and relevant technical specifications.

一、商品分類號列：

C.C.C. Code

二、中文名稱：

Chinese name

三、英文名稱：

English name

四、型 式：

Type

五、系列型式：

Series of the type

倘因違反本聲明書所保證之內容，本申請人願意擔負起所有相關法律責任。

Where violations of this declaration occur, I agree to take the legal responsibilities.

此致

經濟部標準檢驗局

To: The Bureau of Standards, Metrology and Inspection, Ministry of Economic Affairs

申請人：

Applicant:

負責人： （簽章）

Person in charge:	(Signature)

中 華 民 國 年 月 日

Date (year) (month) (day)