Appendix - Form of Safety Certificate for Special Purpose Ships
Clasification Society 2024 - Version 9.40
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Appendix - Form of Safety Certificate for Special Purpose Ships

SPECIAL PURPOSE SHIP SAFETY CERTIFICATE
This Certificate shall be supplemented by a Record of Equipment (Form SPS)
(Official seal) (State)
   
   
Issued in compliance with the provisions of the
CODE OF SAFETY FOR SPECIAL PURPOSE SHIPS
under the authority of the Government of
 
   
  (name of the State)
by  
    (person or organization authorized)
Particulars of shipfootnote
Name of ship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Distinctive number or letters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Port of registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gross tonnage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sea areas in which ship is certificated
to operate (SOLAS regulation IV/2) 		. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
IMO Numberfootnote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ship's special purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date on which keel was laid or ship was at a similar stage of construction or, where applicable, date on which work for a conversion or an alteration or modification of a major character was commenced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
   
THIS IS TO CERTIFY:
1 That the ship has been surveyed in accordance with the requirements of regulation 1.6 of the Code.
2 That the survey showed that:
2.1 the ship complied with the provisions of the Code as regards:
  .1 the structure, main and auxiliary machinery, boilers and other pressure vessels; and
  .2 the watertight subdivision arrangements and details;
2.2 the ship complied with the provisions of the Code as regards structural fire protection, fire safety systems and appliances and fire control plans;
2.3 the life-saving appliances and the equipment of the lifeboats, liferafts and rescue boats were provided in accordance with the provisions of the Code;
2.4 the ship was provided with a line-throwing appliance and radio installations used in life-saving appliances in accordance with the provisions of the Code;
2.5 the ship complied with the provisions of the Code as regards radio installations;
2.6 the functioning of the radio installations used in life-saving appliances complied with the provisions of the Code;
2.7 the ship complied with the provisions of the Code as regards shipborne navigational equipment, means of embarkation for pilots and nautical publications;
2.8 the ship was provided with lights, shapes and means of making sound signals and distress signals, in accordance with the provisions of the Code and the International Regulations for Preventing Collisions at Sea in force; and
2.9 in all other respects the ship complied with the relevant provisions of the Code.
3 That an Exemption Certificate has/hasfootnotenot been issued.
4 That the ship has/has notfootnotebeen provided with Certificates issued under the 1974 SOLAS Convention, as amended.
This certificate is valid until ..................................................................................
Completion date of the survey on which this certificate is based: .......................................
 
(dd/mm/yyyy)
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 FOR ANNUAL SURVEYS RELATING TO HULL, MACHINERY AND EQUIPMENT REFERRED TO IN SECTION 2.1 OF THIS CERTIFICATE
THIS IS TO CERTIFY that at a survey required by 1.6 of the Code, the ship was found to comply with the relevant provisions of the Code.
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
ENDORSEMENT FOR ANNUAL AND PERIODICAL SURVEYS RELATING TO LIFE-SAVING APPLIANCES AND OTHER EQUIPMENT REFERRED TO IN SECTIONS 2.2, 2.3, 2.4, 2.6, 2.7, 2.8 AND 2.9 OF THIS CERTIFICATE
THIS IS TO CERTIFY that at a survey required by 1.6 of the Code, the ship was found to comply with the relevant provisions of the Code.
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual/periodicalfootnote survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual/periodicalfootnote survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
ENDORSEMENT FOR PERIODICAL SURVEYS RELATING TO RADIO INSTALLATIONS REFERRED TO IN SECTION 2.5 OF THIS CERTIFICATE
THIS IS TO CERTIFY that at a survey required by 1.6 of the Code, the ship was found to comply with the relevant provisions of the Code:
Periodical survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Periodical survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Periodical survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Annual survey: Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
ENDORSEMENT FOR THE EXTENSION OF THE CERTIFICATE
The ship complies with the relevant provisions of the Code, and this Certificate should, in accordance with 1.7.3, be accepted as valid until . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  (Signature of authorized official)
  Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Seal or stamp of the Authority, as appropriate)
Parent topic: Annex - Code of Safety for Special Purpose Ships
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