290 



This Certificate is valid until o ^ 



subject to periodical inspection in accordance with 

 Regulation 4 of Liaiex 1 of the said Convention. 



Issued at ..*•••. •••«••••••••••••••>•••<••< 



(Place of issue of certificate) 



(Date of issue) (Signature of official issuing 



the certificate and/or seal of 

 issuing authority) 



If signed, the following paragraph is to be added: 



The undersigned declares that he is duly authorized 

 by the said Govemnent to issue this Certificate, 



Periodical inspections 



This is to certify that at a periodical inspection reqioired by 

 Regulation 4(l)(c) of Annex I of the said Convontion, this ship 

 was found to conply with the relevant provisions of the said 

 C onvention. 



Place Date 



Signature and/or Seal of issuing authority 



Place Date 



Signature and/or Seal of issuing authority 



The provisions of the Convention being fully conplied with bj this ship, 

 the validity of this certificate is, in accordance with Regulation 8(2) 

 of Annex I of the Convention, extended until 



Place Date 



Signature and/or Seal of issuing authority 



