Place and date of issue of the declaration, name and function of the person who signed it as well as an indication for, and on behalf of whom, that person signed, signature.
Ionad agus dáta eisiúna an dearbhaithe, ainm agus feidhm an duine a shínigh chomh maith le tásc don duine ar thar a cheann a shínigh an duine sin, síniú.