Appendix 1 to Annex 4
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - International Conventions - AFS - International Convention on the Control of Harmful Anti-Fouling Systems on Ships, 2001 - Annex 4 - Surveys and Certification Requirements for Anti-Fouling Systems - Appendix 1 to Annex 4

Appendix 1 to Annex 4

 
MODEL FORM OF INTERNATIONAL ANTI-FOULING SYSTEM CERTIFICATE
INTERNATIONAL ANTI-FOULING SYSTEM CERTIFICATE
(This certificate shall be supplemented by a Record of Anti-fouling Systems)
(Official seal) (State)
Issued under the
International Convention on the Control of Harmful Anti-Fouling Systems on Ships
under the authority of the Government of
……………………………………
(name of the State)
by
……………………………………….
(person or organization authorized)
When a Certificate has been previously issued, this Certificate replaces the certificate dated ……....…..
Particulars of ship footnote
Name of ship.......................................................................................................................................
Distinctive number or letters................................................................................................................
Port of registry.....................................................................................................................................
Gross tonnage......................................................................................................................................
IMO numberfootnote.......................................................................................................................................
Has not been applied during or after construction of this ship Has been applied on this ship previously, but has been removed by Has been applied on this ship previously, but has been covered with a sealer coat applied by Has been applied on this ship previously, but is not in the external coating layer of the hull or external parts or surfaces on Was applied on this ship prior to
Organotin compounds which act as biocides □ ……………

(insert name of the facility)

on

……………

(dd/mm/yyyy)

□

 ……………

(insert name of the facility)

on

……………

(dd/mm/yyyy)

□

 Not applicable Not applicable
Cybutryne □ ……………

(insert name of the facility)

on

……………

(dd/mm/yyyy)

□

 ……………

(insert name of the facility)

on

……………

(dd/mm/yyyy)

□

 1 January 2023

□

 1 January 2023, but must be removed or covered with a sealer coat prior to

……………

(dd/mm/yyyy)

□
THIS IS TO CERTIFY THAT:
  • 1 the ship has been surveyed in accordance with regulation 1 of Annex 4 to the Convention; and
  • 2 the survey shows that the anti-fouling system on the ship complies with the applicable requirements of Annex 1 to the Convention.
     
Issued at..........................................................................................................................................
(Place of issue of Certificate)
     
.............................. ............................................................................................
(Date of issue) (Signature of authorized official issuing the Certificate)
     
Date of completion of the survey on which this certificate is issued: ……………………..
 
MODEL FORM OF RECORD OF ANTI-FOULING SYSTEMS
RECORD OF ANTI-FOULING SYSTEMS
This Record shall be permanently attached to the International Anti-Fouling System Certificate.
 
Particulars of ship  
Name of ship : ………………………………….…………...
Distinctive number or letters : ………………………………….…………...
IMO number : ………………………………….…………...
   
Details of anti-fouling system(s) applied
Type(s) of anti-fouling system(s) used ............................................................................................
.......................................................................................................................................................
Date(s) of application of anti-fouling system(s)…………..…………………………………………..
Name(s) of company(ies) and facility(ies)/location(s) where applied ................................................
.......................................................................................................................................................
Name(s) of anti-fouling system manufacturer(s)...............................................................................
.......................................................................................................................................................
Name(s) and colour(s) of anti-fouling system(s)...............................................................................
.......................................................................................................................................................
Active ingredient(s) and their Chemical Abstract Services Registry Number(s) (CAS number(s))
.......................................................................................................................................................
Type(s) of sealer coat, if applicable ………………………………………………………………….
……………………………………………………………………………………………………..….
Name(s) and colour(s) of sealer coat applied, if applicable
………………………………………………………………………………………………………..
Date of application of sealer coat…………………………………………………………….………
   
THIS IS TO CERTIFY that this Record is correct in all respects.
   
Issued at..........................................................................................................................................
(Place of issue of Record)
   
………………………… ............................................................................................
(Date of issue) (Signature of authorized official issuing the record)
 
Endorsement of the Records footnote
THIS IS TO CERTIFY that a survey required in accordance with regulation 1(1)(b) of Annex 4 to the Convention found that the ship was in compliance with the Convention
Details of anti-fouling system(s) applied
Type(s) of anti-fouling system(s) used..............................................................................................
.......................................................................................................................................................
Date(s) of application of anti-fouling system(s)……………………………………………………..
Name(s) of company(ies) and facility(ies) location(s) where applied................................................
.......................................................................................................................................................
Name(s) of anti-fouling system(s) manufacturer(s)...........................................................................
.......................................................................................................................................................
Name(s) and colour(s) of anti-fouling system(s) ...............................................................................
.......................................................................................................................................................
Active ingredient(s) and their Chemical Abstract Services Registry Number(s ) (CAS number(s)) ...
…………………………………………………………………………………………………………
Type(s) of sealer coat, if applicable …………………………………………………………………..
Name(s) and colour(s) of sealer coat applied, if applicable
.………………………………………………………………………………………………………..
Date of application of sealer coat ………………………………………………………………….…
   
  Signed:.....................................................................................
  (Signature of authorized official issuing the Record)
  Place: ......................................................................................
  Datefootnote: ......................................................................................
  (Seal or stamp of the authority)
Parent topic: Annex 4 - Surveys and Certification Requirements for Anti-Fouling Systems
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