Appendix
Forms of the Document of Compliance, the Safety Management Certificate, the Interim Document of Compliance and the Interim Safety Management Certificate
DOCUMENT OF COMPLIANCE
(Official seal)/(State)
Certificate No
Issued under the provisions of the
INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974, as amended
Under the authority of the Government of …
(name of the State)
by …
(person or organisation authorised)
Name and address of the company:
…
…
(see paragraph 1.1.2 of the ISM Code)
THIS IS TO CERTIFY THAT the safety management system of the company has been audited and that it complies with the requirements of the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code) for the types of ships listed below (delete as appropriate):
Passenger ship |
Passenger high-speed craft |
Cargo high-speed craft |
Bulk carrier |
Oil tanker |
Chemical tanker |
Gas carrier |
Mobile offshore drilling unit |
Other cargo ship |
This Document of Compliance is valid until ………, subject to periodical verification.
Issued at …
(place of issue of the document)
Date of issue …
…
(Signature of the duly authorised official issuing the document)
(Seal or stamp of issuing authority, as appropriate)
Certificate No
ENDORSEMENT FOR ANNUAL VERIFICATION
THIS IS TO CERTIFY THAT, at the periodical verification in accordance with Regulation IX/6.1 of the Convention and paragraph 13.4 of the ISM Code, the safety management system was found to comply with the requirements of the ISM Code.
1st ANNUAL VERIFICATION | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... | |
2nd ANNUAL VERIFICATION | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... | |
3rd ANNUAL VERIFICATION | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... | |
4th ANNUAL VERIFICATION | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... |
SAFETY MANAGEMENT CERTIFICATE
(Official seal)/(State)
Certificate No
Issued under the provisions of the
INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974, as amended
Under the authority of the Government of …
(name of the State)
by …
(person or organisation authorised)
Name of ship: …
Distinctive number or letters: …
Port of registry: …
Type of ship (*1): …
Gross tonnage: …
IMO number: …
Name and address of company: …
(see paragraph 1.1.2 of the ISM Code)
THIS IS TO CERTIFY THAT the safety management system of the ship has been audited and that it complies with the requirements of the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code), following verification that the Document of Compliance for the company is applicable to this type of ship.
This Safety Management Certificate is valid until ………, subject to periodical verification and the Document of Compliance remaining valid.
Issued at …
(place of issue of the document)
Date of issue …
(Signature of the duly authorised official issuing the certificate)
(Seal or stamp of issuing authority, as appropriate)
Certificate No
ENDORSEMENT FOR INTERMEDIATE VERIFICATION AND ADDITIONAL VERIFICATION (IF REQUIRED)
THIS IS TO CERTIFY THAT, at the periodical verification in accordance with Regulation IX/6.1 of the Convention and paragraph 13.8 of the ISM Code, the safety management system was found to comply with the requirements of the ISM Code.
INTERMEDIATE VERIFICATION (to be completed between the second and third anniversary date) | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... | |
ADDITIONAL VERIFICATION (*2) | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... | |
ADDITIONAL VERIFICATION (*2) | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... | |
ADDITIONAL VERIFICATION (*2) | Signed: ... |
(Signature of authorised official) | |
Place: ... | |
Date: ... |
INTERIM DOCUMENT OF COMPLIANCE
(Official seal)/(State)
Certificate No
Issued under the provisions of the
INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974, as amended
Under the authority of the Government of …
(name of the State)
by …
(person or organisation authorised)
Name and address of the company: …
(see paragraph 1.1.2 of the ISM Code)
THIS IS TO CERTIFY THAT the safety management system of the company has been recognised as meeting the objectives of paragraph 1.2.3 of the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code), for the type(s) of ships listed below (delete as appropriate):
Passenger ship |
Passenger high-speed craft |
Cargo high-speed craft |
Bulk carrier |
Oil tanker |
Chemical tanker |
Gas carrier |
Mobile offshore drilling unit |
Other cargo ship |
This Interim Document of Compliance is valid until:
Issued at: …
(Place of issue of the document)
Date of issue: …
(Signature of the duly authorised official issuing the document)
(Seal or stamp of issuing authority, as appropriate)
INTERIM SAFETY MANAGEMENT CERTIFICATE
(Official seal)/(State)
Certificate No
Issued under the provisions of the
INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974,
as amended
Under the authority of the Government of …
(name of the State)
by …
(person or organisation authorised)
Name of ship: …
Distinctive number or letters: …
Port of registry: …
Type of ship (*3): …
Gross tonnage: …
IMO number: …
Name and address of company: …
…
(see paragraph 1.1.2 of the ISM Code)
THIS IS TO CERTIFY THAT the requirements of paragraph 14.4 of the ISM Code have been met and that the Document of Compliance/Interim Document of Compliance (*4) of the company is relevant to this ship.
This Interim Safety Management Certificate is valid until …
subject to the Document of Compliance/Interim Document of Compliance (*4) remaining valid.
Issued at …
(place of issue of the document)
Date of issue: …
(Signature of the duly authorised official issuing the certificate)
(Seal or stamp of issuing authority, as appropriate)
Certificate No
The validity of this Interim Safety Management Certificate is extended to: …
Date of extension: …
(Signature of the duly authorised official extending the validity)
(Seal or stamp of issuing authority, as appropriate)
(*1) Insert the type of ship from among the following: passenger ship; passenger high-speed craft; cargo high-speed craft; bulk carrier; oil tanker; chemical tanker; gas carrier; mobile offshore drilling unit; other cargo ship.
(*2) If applicable. Reference is made to paragraph 3.4.1 of the Guidelines on Implementation of the International Safety Management (ISM) Code by Administrations (Resolution A.913(22)).
(*3) Insert the type of ship from among the following: passenger ship; passenger high-speed craft; cargo high-speed craft; bulk carrier; oil tanker; chemical tanker; gas carrier; mobile offshore drilling unit; other cargo ship.
(*4) Delete as appropriate.