(Person / Company name) / (dd/mm/yyyy)
Address:
Phone: / Signatue and Stamp
Fax: /
E-mail:
Main particulars of ship
Name of Ship
Distinctive number or letters
Gross Tonnage
IMO Number
Certificates & Surveys-For each certificate fill the box according to the following letters:
I: Initial // A: Annual // In: Intermediate // P: Periodical R: Renewal // Ad: Additional// C: Change of Name, Flag, RO (Specify)
OS: Other Services (Specify):
SOLAS / MARPOL
IAPRAdCOS / Safety Equipment / IAInPRAdCOS / IOPP (Annex I)
IAPRAdCOS / Safety Radio / IARAdCOS / CAS Survey
IAInRAdCOS / Safety Construction / IAInRAdCOS / NLS (Annex II)
IARAdCOS / Safety Passenger / IARAdCOS / Sewage (Annex IV)
IARAdCOS / IMDG-Code / IARAdCOS / Garbage (Annex V)
IARAdCOS / IMSB-Code / IAInPRAdCOS / Air Pollution (Annex VI)
IRAdCOS / Grain Code (IG-Code) / Revision & Approval / X / YES / — / NO
IAInPRAdOCOS / Other Certificate (Specify): / X-- / SOPEP (Annex I) / SMPEP (Annex II)
X-- / STS Plan (Annex I)
Revision & Approval / X / YES / --- / NO / X-- / VOC Plan (Annex VI)
Stability Booklet / X-- / IEEC + SEEMP (Annex VI)
X-- / Cargo Securing Manual / X-- / BWMP (Ballast Water Management Plan)
X-- / Damage Control Plan / X-- / CBT (Clean Ballast Tank)
X-- / Fire Control Plan / X-- / COW (Crude Oil Washing)
X-- / Loading Manual / X-- / ODMC (Oil Discharge Monitoring & Control System)
Stability Booklet
X-- / Other Plan/Manual Approval (Specify): / X-- / P&A Manual (Procedure & Arrangement)
X-- / Certificate of Type Approval/Type Test Certificate (Specify):
X-- / Other Certificate (Specify):
Load Line / Tonnage
IARCOS / ILL-66 / ICOS / ITC-69
Revision & Approval / X / YES / — / NO / Revision & Approval / X / YES / __ / NO
X-- / Freeboard Calculation / X-- / Tonnage Calculation
X-- / Other Plan/Manual Approval (Specify): / X-- / Other Calculation (Specify):
Certificates & Surveys (Continued)-For each certificate fill the box according to the following letters:
I: Initial // A: Annual // In: Intermediate // P: Periodical R: Renewal // Ad: Additional// C: Change of Name, Flag, RO (Specify) // OS: Other Services (Specify):
ILO Conventions (Accommodation of Crews & Lifting Appliances)
CICA (ILO-68, 92 & 126) / Lifting Appliances (Derricks & Cranes) ILO-152
IRCOS / CICA / X-- / Derricks certification
Maximum of crew members according the accommodation arrangements / Number of derricks / SWL
X-- / Cranes Certification
Number of Cranes / SWL
Other Certificates / Chemical Tankers & Gas Carriers (IBC/IGC Codes)
X-- / Caribbean Code (CCSSC) / IAInRAdCOS / IBC-Code (Chemical Tankers constructed on or after 1-July-1986)
X-- / MODU-Code / IAInRAdCOS / IGC-Code (Gas Carriers constructed on or after 1-July-1986)
X-- / Special Purpose Ships
X-- / High-Speed Craft
X-- / Exemption/Extension CertificateExemption CertificateExtension Certificate
X-- / Permit to Proceed/Letter of Authorization/WaiverPermit to ProceedLetter of AuthorizationWaiver
X-- / Bollard Pull Certification
X-- / Other Certificate (Specify):
Note:Copy of existing certificates and supplements attached to the certificates to be submitted to Class ARS -Head Office including pages with Annual/ Intermediate endorsements
Certification Scenarios
X-- / Change of Recognized Organization / X-- / Re-activation of Statutory Certificates
X-- / Change of Flag / Change of Ship´s Name / X-- / Other Scenario (Specify):
QP 3.1-1/ Form 01 Revision No.1 1/2