EXEMPTION CERTIFICATE

(Official Seal)

Country

Issued under the provisions of the

INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974

The                                (Name) Government certifies

I, the undersigned                                (Name) certify.

That the above-mentioned ship is, under the authority conferred by Regulation ..................... of Chapter....................of the Regulations annexed to the Convention referred to above, exempted from the requirements of ................................of the Convention on the voyages to

This certificate is issued under the authority of the Government. It will remain in force until

Issued at ................................................................. the ........................................ day of.................................................. 19.........

Here follows the seal or signature of the authority entitled to issue the certificate.

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Seal

If signed, the following paragraph is to be added:

The undersigned declares that he is duly authorized by the said Government to issue this certificate.

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Signature