C180 SAFETY OF LIFE AT SEA 



App. 



Form of Exemption Certificate 



EXEMPTION CERTIFICATE 



{Official Seal) (Country) 



Issued under the provisions of the 



International Contention for the S.\fety of Life at Sea, 1960 



Distinctive 

 Name of Ship Number or Pon of Registn Gross Tonnage 



Letters 



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 



oft „ „._ _ - - of the 



Convention on the voyages - ~ 



• Insert here the"! * 

 conditions, if any, on [ 

 which the exemption f 

 cenmcate is granted. J 



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 

 this certificate. 



{Seal) 



If signed, the following paragraph is to be added: — 



The undersigned declares that he is duly authorised by the said Government 

 to issue this certificate. 



{Sigrujture) 



t Insert here references to Chapters and Regulations, specifying particular paragraphs. 



App. 



