Cargo ship Safety Certificate

This Certificate shall be supplemented by a Record of Equipment

(Form С)

(Official seal) (State)

Issued under the provisions of the International Convention

for the Safety of Life at Sea, 1974,

as modified by the Protocol of 1988 relating thereto

under the authority of the Government of

………………………………………………………………………..…

(Name of the State)

by ………………………………………………………………………..

(Person or organized authorized)

Particulars of ship*

Name of ship ……………………………………..………….

Distinctive number or letters ………………………..……….

Port of registry ……………………………………………….

Gross tonnage ………………………………………..………

Deadweight of ship (metric tons)** …………………………

Length of ship (regulation III/3/12) …………………………

Sea areas in which ship is certified to operate

(regulation IV/2) …………………………………………….

IMO Number ……………………………………………..….

Type of ship***

Bulk carrier

Oil tanker

Chemical tanker

Gas carrier

Cargo ship other than any of the above

Date on which keel was laid or ship was at a similar stage of

construction or, where applicable, date on which work for a conver-

sion or an alteration or modification of a major character was

commenced …………………………………………………….

THIS IS TO CERTIFY:

1. That the ship has been surveyed in accordance with the requirements

of regulation 1/8, 1/9 and 1/10 of the Convention.

2. That the survey showed that:

_________________

* Alternatively, the particulars of the ship may be placed horizontally in boxes.

** For oil tankers, chemical tankers and gas carriers only.

*** Delete as appropriate.

2.1. the condition of the structure, machinery and equipment as defined

in regulation 1/10 was satisfactory and the ship complied with the

relevant requirements of chapter II-1 and chapter II-2 of the Convention

(other than those relating to fire safety systems and appliances and fire

control plans);

2.2. the last two inspections of outside of the ship's bottom took

place on …………………… and …………………………

(Dates)

2.3. the ship complied with the requirements of the Convention as

regards fire safety systems and appliances and fire control plans;

2.4. the life--saving appliances and the equipment of the lifeboats, life-

rafts and rescue boats were provided in accordance with the requirements

of the Convention;

2.5. the ship was provided with a line-throwing appliance and radio

installations used in life-saving appliances with the requirements

of the Convention;

2.6. the ship complied with the requirements of the Convention as

regards radio installations;

2.7. the functioning of the radio installations used in life-saving appliances

complied with the requirements of the Convention;

2.8. the ship complied with the requirements of the Convention as

regards shipborne navigational equipment, means of embarkation

for pilots and nautical publications;

2.9. the ship was provided with lights shapes, means of making sound

signals and distress signals in accordance with the requirements

of the Convention and the International Regulations for Preventing

Collisions at Sea in force;

2.10. in all other respects, the ship complied with the relevant requirements

of the Convention.

3. That an Exemption Certificate has/has not*been issued.

This Certificate is valid until ……………………** subject to the annual,

intermediate and periodical surveys and inspections of the ship's bottom in accordance with regulation 1/8, 1/9 and 1/10 of the Convention.

Issued at ……………………………………………………………...

(Place of issue of Certificate)

………………… ……………………………..

(Date of issue) (Signature of authorized official

issuing the Certificate)

(Seal or stamp of the issuing authority, as appropriate)

_____________

* Delete as appropriate.

** Insert the date of expiry as specified by the Administration in accordance with regula-

tion 1/14(a) of the Convention. The day and the month of this date correspond to the

anniversary date as defined in regulation 1/2(n) of the Convention, unless amended in

accordance with regulation 1/14(h).

Endorsement for annual and intermediate surveys relating

to structure, machinery and equipment referred to in paragraph 2.1

of this Certificate

THIS IS TO CERTIFY that, at survey required by regulation 1/10 of the

Convention, the ship was found to comply with the relevant requirements

of the Convention.

Annual survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual/Intermediate* survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual/Intermediate* survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual/Periodical survey in accordance with regulation 1/14(h)(iii)

THIS IS TO CERTIFY that, at an annual/intermediate* survey in

accordance with regulation 1/10 and 1/14(h)(iii) of the Convention, the ship

was found to comply with the relevant requirements of the Convention.

Signed: …………………………………..…

(Signature of authorized official)

Place: ……………………………………….

Date: …………………………………..……

(Seal or stamp of authority, as appropriate)

______________

* Delete as appropriate.

Endorsement for inspection of the outside of the ship's bottom**

THIS IS TO CERTIFY that, at an inspection required by regulation 1/10

of the Convention, the ship was found to comply with the relevant

requirements of the Convention.

First inspection: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Second inspection: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Endorsement for periodical surveys

THIS IS TO CERTIFY that, at survey required by regulation 1/9 f the

Convention, the ship was found to comply with the relevant requirements

of the Convention.

Annual survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual/Periodical* survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual/Periodical* survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Annual survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

_____________

* Provision may be made for additional inspections.

** Delete as appropriate.

Annual/Periodical survey in accordance with regulation 1/14(h)(iii)

THIS IS TO CERTIFY that, at an annual/periodical* survey in

accordance with regulation 1/8 and 1/14(h)(iii) of the Convention, the ship was

found to comply with the relevant requirements of the Convention.

Signed: …………………………………..…

(Signature of authorized official)

Place: ……………………………………….

Date: …………………………………..……

(Seal or stamp of authority, as appropriate)

Endorsement for periodical surveys relating to radio installations

referred to in paragraphs 2.6 and 2.7 of this Certificate

THIS IS TO CERTIFY that, at survey required by regulation 1/9 f the

Convention, the ship was found to comply with the relevant requirements

of the Convention.

Periodical survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Periodical survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Periodical survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

Periodical survey: Signed: ………………………..…

(Signature of authorized official)

Place: …………………………….

Date: ………………………..……

(Seal or stamp of authority, as appropriate)

_______________

* Delete as appropriate.

Periodical survey in accordance with regulation 1/14(h)(iii)

THIS IS TO CERTIFY that, at a periodical survey in accordance with

regulation 1/9 and 1/14(h)(iii) of the Convention, the ship was found to comply

with the relevant requirements of the Convention.

Signed: …………………………………..…

(Signature of authorized official)

Place: ……………………………………….

Date: …………………………………..……

(Seal or stamp of authority, as appropriate)