[ ② Delete as appropriate.]
Annual/Periodical
① Survey: Signed: ---------------------------------------------
(Signature of authorized official)
Place: -------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
[ ① Insert the date of expiry as specified by the Administration in
accordance with regulation I/14(a) of the Convention. The day and the
month of this date correspond to the anniversary date as defined in
regulation I/2 (n) of the Convention, unless amended in accordance with
regulation I/14(h).]
Annual survey: Signed: ----------------------------------------------
(Signature of authorized official)
Place: -----------------------------------------------
Date: ------------------------------------------------
(Seal or stamp of the authority, as appropriate)
Annual/periodical survey in accordance with regulation I/14 (h) (iii)
THIS IS TO CERTIFY that, at the annual/periodical ①survey in
accordance with regulation I/14 (h) (iii) of the Convention, the ship was
found to comply with the relevant requirements of the convention.
Signed: -------------------------------------------------
(Signature of authorized official)
Place: --------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
Endorsement to extend the certificate if valid for less than 5 years
where regulation I/14 (c) applies
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 -----------------------------
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
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 -----------------------------
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) orI/14 (f) applies
This certificate shall, in accordance with regulation I/14(e)/I/14(f)
① of the Convention, be accepted as valid until -------------------------
----------------------------------------------
[ ① Delete as appropriate.]
Signed: -------------------------------------------------
(Signature of authorized official)
Place: --------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
Endorsement for advancement of anniversary date where regulation I/14
(h) applies
In accordance with regulation I/14(h) of the Convention, the new
anniversary date is
----------------------------------------------------------------------
Signed: -------------------------------------------------
(Signature of authorized official)
Place: --------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
In accordance with regulation I/14(h) of the Convention, the new
anniversary date is
----------------------------------------------------------------------
Signed: -------------------------------------------------
(Signature of authorized official)
Place: -------------------------------------------------
Date: -------------------------------------------------
(Seal or stamp of the authority, as appropriate)
Form E''s Record of Equipment for the Cargo Ship Safety EquipmentCertificate
This Record shall be permanently attached to the Cargo Ship Safety
Equipment Certificate
RECORD OF EQUIPMENT FOR COMPLIANCE WITH THE INTERNATIONAL CONVENTION FORTHE SAFETY OF LIFE AT SEA, 1974, AS MODIFIED BY THE PROTOCOL OF 1988
RELATING THERETO
1 Particulars of ship
Name of ship --------------------------------------------------------
Distinctive number or letters ---------------------------------------
2 Details of life-saving appliances
＜font size=+1＞
|----------------------------------------------------------------------------------
| 1 Total number of persons for which life-saving |
| appliances are provided …………… |
|---------------------------------------------------------------------------------|
| | Port| Starboard |
| | side| side |
| |-----|-----------|
| | | |
| 2 Total number of lifeboats | ……| ………… |
| 2.1 Total number of persons accommodated by them | ……| ………… |
| 2.2 Number of self-righting partially enclosed lifeboats | | |
| (regulation III/43) | | |
| 2.3 Number of totally enclosed lifeboats (regulation III/44)| ……| ………… |
| 2.4 Number of lifeboats with a self-contained air support | | |
| system (regulation | ……| ………… |
| III/45) | | |
| 2.5 Number of fire-protected lifeboats (regulation III/46) | ……| ………… |
| 2.6 Other lifeboats | ……| ………… |
| 2.6.1 Number | | |
| 2.6.2 Type | ……| ………… |
| | ……| ………… |
| 2.7 Number of freefall lifeboats | |
| 2.7.1 Totally enclosed (regulation III/44) | ……… |
| 2.7.2 Self-contained (regulation III/45) | ……… |
| 2.7.3 Fire-protected (regulation III/46) | ……… |
| 3 Number of motor lifeboats (included in the total | |
| lifeboats shown above) | ……… |
| 3.1 Number of lifeboats fitted with searchlights | ……… |
| | |
| 4 Number of rescue boats | …………………|
| 4.1 Number of boats which are included | |
| in the total lifeboats shown above | …………………|
| 5 Liferafts | |
| 5.1 Those for which approved launching | |
| appliances are required | |
| 5.1.1 Number of liferafts | …………………|
| 5.1.2 Number of persons accommodated by them | …………………|
| 5.2 Those for which approved launching | |
| appliances are not required | |
| 5.2.1 Number of liferafts | …………………|
| 5.2.2 Number of persons accommodated by them | …………………|
| | |
| 5.3 Number of liferafts required by regulation III/26.1.4 | …………………|
| | |
| 6 Number of lifebuoys | …………………|
| | |
| 7 Number of lifejackets | …………………|
| 8 Immersion suits | |
| 8.1 Total number | …………………|
| 8.2 Number of suits complying with | |
| the requirements for lifejackets | …………………|
| | |
| 9 Number of thermal protective aids ① | …………………|
| | |
| 10 Radio installations used in | |
| life-saving appliances | |
| 10.1 Number of radar transponders | …………………|
| | |
| 10.2 Number of two-way VHF radiotelephone apparatus | …………………|
|----------------------------------------------------------------------------------
＜/font＞
[ ① Excluding those required by regulations III/38.5.1.24,
III/41.8.31 and III/47.2.2.13.]
3 Ships constructed before 1 February 1992 which do not fully comply
with the applicable requirements of chapter III of the Convention as
amended in 1988 ②
[ ② This section need not be reproduced on the record attached to
certificates issued after 1 February 1995.]
＜font size=+1＞
|-----------------------------------------------------------------------
| | Actual |
| | provision|
|-----------------------------------------------------------|----------|
| Radiotelegraph installation for lifeboat | ……… |
| | |
| Portable radio apparatus for survival craft | ……… |
| | |
| Survival craft EPIRB (121.5 MHz and 243.0 MHz) | ……… |
| | |
| Two-way radiotelephone apparatus | ……… |
|-----------------------------------------------------------------------
＜/font＞
THIS TO CERTIFY that this Record is correct in all respects
Issued at -------------------------------------------------------
(Place of issue of the Record)
----------------------------- ----------------------------------
(Date of Issue) (Signature of duly authorized
official issuing the Record)
(Seal or stamp of the issuing authority, as
appropriate)
Form R (Safety Radio Certificate for Cargo Ships)
CARGO SHIP SAFETY RADIO CERTIFICATE
This Certificate shall be supplemented by a Record of Equipment of RadioFacilities (Form R)
(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 ①
[ ① Alternatively, the particulars of the ship may be placed
horizontally in boxes.]
Name of ship ---------------------------------------------------------
Distinctive number or letters ----------------------------------------
Port of registry -----------------------------------------------------
Gross tonnage --------------------------------------------------------
Sea areas in which ship is certified to operate
(Regulation IV/2) ----------------------------------------------------
IMO Number② --------------------------------------------------------
[ ② In accordance with resolution A. 600(15)-IMO ship Identification
Number Scheme, this information may be included voluntarily.]
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 I/9 of the Convention.
2 That the survey showed that:
2.1 the ship complied with the requirements of the Convention as
regards radio installations;
2.2 the functioning of the radio installations used in life-saving
appliances complied with the requirements of the Convention;
3 That an Exemption Certificate has/has not ① been issued.
[ ① Delete as appropriate.]
This certificate is valid until ----------------------② subject to
the periodical surveys in accordance with regulation I/9 of the Convention
[ ② Insert the date of expiry as specified by the Administration in
accordance with regulation I/14 (a) of the Convention. The day and the
month of this date correspond to the anniversary date as defined in
regulation I/2 (n) of the Convention, unless amended in accordance withregulation I/14 (h).]
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 periodical surveys
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 requirementsof the Convention.
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)
Periodical survey: Signed: ------------------------------------------
(Signature of authorized official)
Place: -------------------------------------------
Date: --------------------------------------------
(Seal or stamp of the authority, as appropriate) Periodical
survey in accordance with regulation I/14 (h) (iii)
THIS IS TO CERTIFY that, at a periodical survey in accordance with
regulation I/14 (h) (iii) of the Convention, the ship was found to comply
with the relevant requirements of the Convention.
Signed: ------------------------------------------
(Signature of authorized official)
Place: -------------------------------------------
Date: --------------------------------------------
(Seal or stamp of the authority, as appropriate)
Endorsement to extend the certificate if valid for less than 5 years
where regulation I/14 (c) applies
The ship complies with the relevant requirements of the Convention,
and this certificate shall, in accordance with regulation I/14(c) of theconvention, be accepted as valid until -----------------------------
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
The ship complies with the relevant requirements of the Convention,
and this certificate shall, in accordance with regulation I/14(d) of theConvention, be accepted as valid until -----------------------------
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)
① of the Convention, be accepted as valid until -------------------------
-------------------------
[ ① Delete as appropriate.]
Signed: -------------------------------------------------
(Signature of authorized official)
Place: --------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
Endorsement for advancement of anniversary date where regulation I/14
(h) applies
In accordance with regulation I/14(h) of the Convention, the new
anniversary date is
-------------------------------------------------------------------------
Signed: -------------------------------------------------
(Signature of authorized official)
Place: --------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
In accordance with regulation I/14(h) of the Convention, the new
anniversary date is
-------------------------------------------------------------------------
Signed: -------------------------------------------------
(Signature of authorized official)
Place: --------------------------------------------------
Date: ---------------------------------------------------
(Seal or stamp of the authority, as appropriate)
Form R''s Record of Equipment for the Cargo Ship Safety Radio Certificate
This Record shall be permanently attached to the Cargo Ship Safety RadioCertificate
RECORD OF EQUIPMENT OF RADIO FACILITIES FOR COMPLIANCE WITH THE
INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974, AS MODIFIED
BY THE PROTOCOL OF 1988 RELATING THERETO
1 Particulars of ship
Name of ship ---------------------------------------------------------
Distinctive number or letters ----------------------------------------
Minimum number of persons with required
qualifications to operate the radio installations --------------------
2 Details of radio facilities
＜font size=+1＞
|-----------------------------------------------------------------------
| | |
| Item | Actual provision |
| | |
|-----------------------------------------|----------------------------|
| 1 Primary systems | |
| | |
| 1.1 VHF radio installation | |
| | |
| 1.1.1 DSC encoder | ………………………………… |
| | |
| 1.1.2 DSC watch receiver | ………………………………… |
| | |
| 1.1.3 Radiotelephony | ………………………………… |
| | |
| 1.2 MF radio installation | |
| | |
| 1.2.1 DSC encoder | ………………………………… |
| | |
| 1.2.2 DSC watch receiver | ………………………………… |
| | |
| 1.2.3 Radiotelephony | ………………………………… |
| | |
| 1.3 MF/HF radio installation | |
| | |
| 1.3.1 DSC encoder | ………………………………… |
| | |
| 1.3.2 DSC watch receiver | ………………………………… |
| | |
| 1.3.3 Radiotelephony | ………………………………… |
| | |
| 1.3.4 Direct-printing telegraphy | ………………………………… |
| | |
| 1.4 INMARSAT ship earth station | ………………………………… |
| | |
|-----------------------------------------------------------------------
＜/font＞
