CARGO SHIP SAFETY CERTIFICATE
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This Certificate shall be supplemented by a Record of Equipment
for Cargo Ship Safety (Form C)
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(Official seal)
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(State)
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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
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under the authority of the Government of
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_______________________________
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(name of the State)
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by _______________________________
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(person or organization authorized)
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Particulars of shipfootnote
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Name of ship
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Distinctive number or letters
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Port of registry
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Gross tonnage
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Deadweight of ship (metric tons)footnote
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Length of ship (regulation
III/3.12)
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Sea areas in which the ship is certified to operate
(regulation IV/2)
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IMO Numberfootnote
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Type of shipfootnote
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Bulk
carrier
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Oil
tanker
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Chemical
tanker
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Gas
carrier
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Cargo ship
other than any of the above
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Date of Build:
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Date of building contract
......................................................................................................................
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Date on which keel was laid or ship was at similar
stage of construction .................................
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Date of delivery
.......................................................................................................................
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Date on which work for a conversion or an alteration
or modification of a major character was commenced (where applicable)
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All applicable dates shall be completed.
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THIS IS TO CERTIFY:
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1 That the ship has been surveyed in accordance with
the requirements of regulations I/8, I/9
and I/10 of the Convention.
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2 That the survey showed that:
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2.1 the
condition of the structure, machinery and equipment as defined in regulation
I/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);
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2.2 the
last two inspections of the outside of the ship's bottom took place on
.................................... and
.................................... (dates)
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2.3 the
ship complied with the requirements of the Convention as regards fire safety
systems and appliances and fire control plans;
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2.4 the
life-saving appliances and the equipment of the lifeboats, liferafts and
rescue boats were provided in accordance with the requirements of the
Convention;
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2.5 the
ship was provided with a line-throwing appliance and radio installations
used in life-saving appliances in accordance with the requirements of the
Convention;
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2.6 the
ship complied with the requirements of the Convention as regards radio
installations;
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2.7 the
functioning of the radio installation used in life-saving appliances
complied with the requirements of the Convention;
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2.8 the
ship complied with the requirements of the Convention as regards shipborne
navigational equipment, means of embarkation for pilots and nautical
publications;
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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;
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2.10 in
all other respects, the ship complied with the relevant requirements of the
Convention;
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2.11 the ship was/was notfootnote subjected to an alternative design and arrangements in
pursuance of regulation(s) II-1/55 / II-2/17 / III/38
footnote of the Convention;
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2.12 a Document of approval of alternative design and
arrangements for machinery and electrical installations/fire
protection/life-saving appliances and arrangementsfootnote is/is notfootnote appended to this Certificate.
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3 That
the ship operates in accordance with regulation III/26.1.1.1
footnote within the limits of the trade area
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4 That an
Exemption Certificate has/has notfootnote been issued.
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This certificate is valid until
...................................footnote subject to the annual, intermediate and periodical surveys
and inspections of the outside of the ship's bottom in accordance with regulations
I/8, I/9 and I/10
of the Convention.
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Completion date of the survey on which this
certificate is based: ....................................
(dd/mm/yyyy)
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Issued at
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(Place of issue of certificate)
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..............................................
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(Date of Issue)
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(Signature of authorized official issuing the certificate)
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(Seal or stamp of the issuing authority, as
appropriate)
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Endorsement for annual and intermediate surveys relating to structure,
machinery and equipment referred to in paragraph 2.1 of this
certificate
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THIS IS
TO CERTIFY that, at a survey required by regulation
I/10 of the Convention, the ship was found to comply with the
relevant requirements of the Convention.
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Annual survey:
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Signed:
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(Signature
of authorized official)
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Place:
.........................................................
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual/Intermediatefootnote survey:
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual/Intermediatefootnote survey:
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the authority, as appropriate)
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Annual/intermediate survey in accordance with regulation I/14(h)(iii)
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THIS IS TO CERTIFY that, at an
annual/intermediatefootnote survey in accordance with regulations
I/10 and I/14(h)(iii) of the Convention, the ship was found to
comply with the relevant requirements of the Convention.
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Signed:
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(Signature
of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Endorsement for inspections of the outside of the ship's bottomfootnote
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THIS IS TO CERTIFY that, at an inspection required by
regulation I/10 of the Convention, the ship was found to comply
with the relevant requirements of the Convention.
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First inspection:
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Second inspection:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Endorsement for annual and periodical surveys relating to life-saving
appliances and other equipment referred to in paragraphs 2.3, 2.4,
2.5, 2.8 and 2.9 of this certificate
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THIS IS TO CERTIFY that, at a survey required by regulation
I/8 of the Convention, the ship was found to comply with the
relevant requirements of the Convention.
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Annual survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
.........................................................
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual/Periodicalfootnote survey:
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Signed:
.......................................................
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(Signature
of authorized official)
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Place:
.........................................................
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual/Periodicalfootnote survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
.........................................................
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Annual/periodical survey in accordance with regulation I/14(h)(iii)
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THIS IS TO CERTIFY that, at an annual/periodicalfootnote survey in accordance with regulations
I/8 and I/14(h)(iii) of the Convention, the ship was found to
comply with the relevant requirements of the Convention.
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Signed:
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(Signature
of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Endorsement for periodical surveys relating to radio installations
referred to in paragraphs 2.6 and 2.7 of this certificate
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THIS IS TO CERTIFY that, at a survey required by regulation
I/9 of the Convention, the ship was found to comply with the
relevant requirements of the Convention.
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Periodical survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Periodical survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
.........................................................
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Periodical survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Periodical survey:
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Signed:
.......................................................
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(Signature of authorized official)
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Place:
.........................................................
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Date:
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(Seal or stamp of the authority, as
appropriate)
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Periodical survey in accordance with regulation I/14(h)(iii)
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THIS IS TO CERTIFY that, at a periodical survey in
accordance with regulations I/9 and I/14(h)(iii) of the Convention, the ship was found to comply with
the relevant requirements of the Convention.
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Endorsement to extend the Certificate if valid for less than 5 years
where regulation I/14/(c) applies
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The ship complies with the relevant requirements of
the Convention, and this certificate shall, in accordance with regulation
I/14(c) of the Convention, be accepted as valid until
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Endorsement where the renewal survey has been completed and regulation I/14/(d) applies
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The ship complies with the relevant requirements of
the Convention, and this certificate shall, in accordance with regulation
I/14(d) of the Convention, be accepted as valid until
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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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
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This certificate shall, in accordance with regulation
I/14(e) / I/14(f)
footnote of the Convention, be accepted as valid until
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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Endorsement for advancement of anniversary date where regulation I/14(h) applies
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In accordance with regulation
I/14(h) of the Convention, the new anniversary date is
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the
authority, as appropriate)
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In accordance with regulation
I/14(h) of the Convention, the new anniversary date is
...........................................................................
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Signed:
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(Signature of authorized official)
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Place:
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Date:
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(Seal or stamp of the authority, as
appropriate)
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