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    Malaysia Marine Department: Appendix 1

    Uploaded by

    Rhona Escobar
    This document contains an application form for exemption or extension from national and international convention requirements. The form requests information about the applicant, vessel details, voyage details, and reasons for requesting either an exemption certificate or extension of an existing certificate. It also includes spaces for recommendations from a Recognized Organization, a declaration by the Master/Manager/Owner, and remarks from the flag state related to the application.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Malaysia Marine Department: Appendix 1

    Uploaded by

    Rhona Escobar
    47 views3 pages
    This document contains an application form for exemption or extension from national and international convention requirements. The form requests information about the applicant, vessel details, voyage details, and reasons for requesting either an exemption certificate or extension of an existing certificate. It also includes spaces for recommendations from a Recognized Organization, a declaration by the Master/Manager/Owner, and remarks from the flag state related to the application.

    Original Description:

    Original Title

    Appendix1(2)

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    This document contains an application form for exemption or extension from national and international convention requirements. The form requests information about the applicant, vessel details, voyage details, and reasons for requesting either an exemption certificate or extension of an existing certificate. It also includes spaces for recommendations from a Recognized Organization, a declaration by the Master/Manager/Owner, and remarks from the flag state related to the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    47 views3 pages

    Malaysia Marine Department: Appendix 1

    Uploaded by

    Rhona Escobar
    This document contains an application form for exemption or extension from national and international convention requirements. The form requests information about the applicant, vessel details, voyage details, and reasons for requesting either an exemption certificate or extension of an existing certificate. It also includes spaces for recommendations from a Recognized Organization, a declaration by the Master/Manager/Owner, and remarks from the flag state related to the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Appendix 1

    Malaysia Marine Department

    APPLICATION FOR THE EXEMPTION OR EXTENSION FROM NATIONAL AND INTERNATIONAL CONVENTION
    REQUIREMENT
    To : Survey General Of Ships
    Malaysia Marine Department.

    Applicant’s details:
    Title : Mr / Mrs / Miss
    Name :

    Postal address :

    City : Postcode :

    Phone (daytime) Mobile : Fax :


    E-mail Address :

    Particulars of ship
    Vessel Name : IMO Number :

    Official Number : Type of Ship :

    Call sign : Year of built :

    GRT : Other(s) :
    Trading/Plying Recognised
    : :
    area Organisation
    Voyage details
    Estimated departure date : Estimated arrival date :

    Departure port : Arrival port :

    EXEMPTION
    Exemption certificate of :
    Exempted from the requirements :

    Convention :

    Conferred by the Regulations of :

    Reasons to support the application :

    Duration requested for exemption :


    EXTENSION

    Extension certificate of :

    Other :

    Convention :

    Conferred by the Regulations of :

    Reason(s) to support the :


    application

    Name of shipyard(if repair, dry


    :
    docking, special survey, etc)
    Location of shipyard :

    Expected Date Duration requested for


    : :
    extension
    Safety Measure taken by applicant’s

    Recognized Organization recommendations related to this application

    Date : Surveyor :
    ( )
    Declaration by the Master/Manager/Owner of Vessel

    I/we*, the undersigned, hereby declare that the above mentioned vessel has not been subjected to any
    accident or other occurrence which would raise any doubt as to the vessel continuing to be seaworthy and that
    she is properly equipped to operate within the limits prescribed in the said Certificate.

    Date : …………………………………………………………
    (Master/Manager/Owner of Vessel)
    Flag State remarks related to this application

    …………………………………………
    Date : ( )

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