Form of Exemption Certificate

EXEMPTION CERTIFICATE

(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 organization authorized)

*Particulars of ship* ^footnote
Name of ship ........................................................................................................................
Distinctive number or letters ................................................................................................
Port of registry .....................................................................................................................
Gross tonnage .....................................................................................................................
IMO Number^footnote .........................................................................................................................

THIS IS TO CERTIFY:
That the ship is, under the authority conferred by regulation ....................................... of the Convention, exempted from the requirements of .............................................................................................................................................. of the Convention.

Conditions, if any, on which the Exemption Certificate is granted: ............................................................................................................................................. ..............................................................................................................................................

Voyages, if any, for which the Exemption Certificate is granted: ............................................................................................................................................. ..............................................................................................................................................

*This certificate is valid until* ............................................................... subject to the ...................................................................................................... Certificate, to which this certificate is attached, remaining valid.

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)

*Endorsement to extend the certificate if valid for less than 5 years where regulation I/14(c) applies*
This certificate shall, in accordance with regulation I/14(c) of the Convention, be accepted as valid until ...................................................................... subject to the ............................................................ Certificate, to which this certificate is attached, remaining valid.

	Signed: .......................................................
	(Signature of authorized official)
	Place: .........................................................
	Date: ..........................................................
	(Seal or stamp of the authority, as appropriate)

*Endorsement where the renewal survey has been completed and regulation I/14(d) applies*
This certificate shall, in accordance with regulation I/14(d) of the Convention, be accepted as valid until ...................................................................... subject to the ............................................................ Certificate, to which this certificate is attached, remaining valid.

	Signed: .......................................................
	(Signature of authorized official)
	Place: .........................................................
	Date: ..........................................................
	(Seal or stamp of the authority, as appropriate)

Endorsement to extend the validity of the certificate until reaching the port of survey or for a period of grace where regulation I/14(e) or I/14(f) applies
This certificate shall, in accordance with regulation I/14(e) / I/14(f) ^footnote of the Convention, be accepted as valid until ...................................................................... subject to the ............................................................ Certificate, to which this certificate is attached, remaining valid.

	Signed: .......................................................
	(Signature of authorized official)
	Place: .........................................................
	Date: ..........................................................
	(Seal or stamp of the authority, as appropriate)