(Regulation I/12.1)
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FORM OF CERTIFICATE OF INSPECTION
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COAT OF
ARMS
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[COUNTRY] [Administration]
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Certification Date:
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CERTIFICATE OF INSPECTION
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Expiration
Date:
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VESSEL
NAME
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IDENTITY MARK
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CALL
SIGN
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SERVICE
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HOME
PORT
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HULL MATERIAL
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POWER
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PROPULSION
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PLACE
BUILT
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DATE BUILT
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GROSS
TONNAGE
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NET TONNAGE
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LENGTH
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OWNER
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OPERATOR
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THIS VESSEL
SHALL BE MANNED WITH THE FOLLOWING PERSONNEL:
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- __ MASTER, BOATMASTER GRADE
- __ MATE, BOATMASTER GRADE
- __ BOAT ENGINEER GRADE 1
- __ BOAT ENGINEER GRADE 2
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- __ DECK RATINGS CATEGORY 1
- __ DECK RATINGS CATEGORY 2
__ DECK RATINGS CATEGORY 3
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__DECK RATINGS CATEGORY 4
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IN ADDITION,
THIS VESSEL MAY CARRY
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_______ PASSENGERS;
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_______
OTHER PERSONS IN CREW;
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_______
PERSONS IN ADDITION
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TO CREW, AND
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TOTAL PERSONS ALLOWED:
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OPERATING
AREA AND CONDITIONS OF OPERATION
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WITH THIS
INSPECTION HAVING BEEN COMPLETED AT
......................................................... ON ...............,
THIS VESSEL IS CERTIFIED BY
........................................................................................,
TO BE IN ALL RESPECTS IN CONFORMITY WITH THE APPLICABLE VESSEL INSPECTION
LEGISLATION.
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ANNUAL INSPECTIONS
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THIS
CERTIFICATE ISSUED BY:
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DATE
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PLACE
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SIGNATURE
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________________________________________________ (AUTHORISED
OFFICIAL)
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________________________________________________
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(DESIGNATION)
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VESSEL
NAME
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IDENTITY MARK
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CERTIFICATION DATE:
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PAGE
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CONDITIONS
OF OPERATION (CONTINUED)
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DRY DOCKING
AND OTHER EXAMINATIONS
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VESSEL
NAME
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IDENTITY MARK
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CERTIFICATION DATE:
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PAGE
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LIFESAVING EQUIPMENT
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NUMBER
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PERSONS
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REQUIRED
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TOTAL EQUIPMENT FOR
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LIFE PRESERVERS (ADULT)
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LIFEBOATS (TOTAL)
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LIFE PRESERVERS (CHILD)
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LIFEBOATS (PORT) *
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LIFE BUOYS (TOTAL)
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LIFEBOATS (STARBOARD) *
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WITH LIGHTS *
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MOTOR LIFEBOATS *
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WITH LINE ATTACHED*
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LIFEBOATS W/RADIO *
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OTHER*
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RESCUE BOATS/PLATFORMS
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IMMERSION SUITS
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INFLATABLE RAFTS
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PORTABLE LIFEBOAT RADIOS
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LIFE FLOATS/ BOUYANT APPARATUS
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EQUIPPED WITH EPIRB?
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WORKBOATS (NOT REQUIRED)
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( * INCLUDED IN TOTALS )
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FIRE FIGHTING EQUIPMENT
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TOTAL HOSE LENGTH
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NUMBER OF FIRE AXES
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NUMBER OF FIRE PUMPS
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FIXED EXTINGUISHING SYSTEMS
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SPACE PROTECTED
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AGENT
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CAPACITY
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FIRE EXTINGUISHERS – HAND, PORTABLE AND SEMI – PORTABLE
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EXEMPTIONS
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