Declaration for Mirror Certification

Declaration by Primary Certificate Holder
I	Primary Certificate holder contact name
Representative of	Primary Certificate holder company name
Declare that	Original Product name(s) as recorded on Primary Certificate
Are manufactured in their entirety (including all manufacturing, finishing, labelling and marking) at	Address of manufacturing facility, should be same as the primary certificate FPC address
No additional work is performed at	Name & address of mirror certificate applicant
Signed (in agreement of declaration on page 2)	Signature of Primary Certificate holder
Date	Date the declaration form is signed

Declaration by Mirror Certificate Applicant
I	Applicant Contact Name
Representative of	Mirror Certificate applicant company name
Declare that	Original Product name(s) as recorded on Primary Certificate
Are manufactured in their entirety (including all manufacturing, finishing, labelling and marking) at	Address of manufacturing facility, should be same as the primary certificate FPC address
No additional work is performed at	Address of mirror certificate applicant
Signed	Signature of mirror certificate applicant
Date	Date the declaration form is signed

By signing the above declaration both parties are confirming the following:

The Mirror Certificate holder will not in any way change or modify the manufactured product, packaging or labelling as supplied by the original Primary Certificate holder.

If any changes are made by the Mirror Certificate holder in the future (e.g. modification of product, item removal or replacement, changes to labelling or marking, etc.), the Mirror Certificate holder will notify Warringtonfire immediately.

Incorrect information supplied on this form, or failure to notify Warringtonfire of subsequent changes to the Mirror Certificate product, will result in withdrawal of the Mirror Certificate.