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EXEMPTION CERTIFICATE
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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 amended
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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 ship
footnote
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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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| IMO Numberfootnote
.........................................................................................................................
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THIS IS TO CERTIFY:
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| That the ship
is, under the authority conferred by regulation
....................................... of the Convention, exempted from the
requirements of
..............................................................................................................................................
of the Convention.
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Conditions,
if any, on which the Exemption Certificate is
granted:
.............................................................................................................................................
..............................................................................................................................................
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Voyages, if
any, for which the Exemption Certificate is
granted:
.............................................................................................................................................
..............................................................................................................................................
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This certificate is valid until
............................................................... subject to
the
......................................................................................................
Certificate, to which this certificate is attached, remaining valid.
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| Issued at
..............................................................................................................................
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(Place of issue of certificate)
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| ..............................................
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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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