ANNEX

‘5. Form of Documents of Compliance and Safety Management Certificates

When ships operate only in a Member State, Member Sates shall either use the forms attached to the ISM Code or the Document of Compliance, the Safety Management Certificate, the Interim Document of Compliance and the Interim Safety Management Certificate drawn up in the form set out below.

In the event of a derogation under Article 7(1) and, if applicable, Article 7(2), the certificate issued shall be different from the one referred to above and clearly indicate that a derogation in accordance with Article 7(1) and, if applicable, Article 7(2) of this Regulation, has been granted and shall include the applicable operational limitations.

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 and] (1) of Regulation (EC) No 336/2006 on the implementation of the ISM Code within the Community

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 Part A of Annex I to Regulation (EC) No 336/2006)

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

Ro-ro passenger ship (ro-ro ferry)

This Document of Compliance is valid until …, subject to periodical verification.

Completion date of the verification on which this certificate is based …

(dd/mm/yyyy)

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 and] (2) Article 6 of Regulation (EC) No 336/2006 on the implementation of the ISM Code within the Community, the safety management system was found to comply with the requirements of the ISM Code.

FIRST ANNUAL VERIFICATION Signed: … (Signature of authorised official) Place: … Date: … SECOND ANNUAL VERIFICATION Signed: … (Signature of authorised official) Place: … Date: … THIRD ANNUAL VERIFICATION Signed: … (Signature of authorised official) Place: … Date: … FOURTH 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] and (3) of Regulation (EC) No 336/2006 on the implementation of the ISM Code within the Community

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 (4): …

Gross tonnage: …

IMO Number: …

Name and address of company: …

(see paragraph 1.1.2 of Part A of Annex I to Regulation (EC) No 336/2006)

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.

Completion date of the verification on which this certificate is based …

(dd/mm/yyyy)

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 and] (5) Article 6 of Regulation (EC) No 336/2006 on the implementation of the ISM Code within the Community, 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 (6) Signed: … (Signature of authorised official) Place: … Date: … ADDITIONAL VERIFICATION (6) Signed: … (Signature of authorised official) Place: … Date: … ADDITIONAL VERIFICATION (6) 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 and] (7) of Regulation (EC) No 336/2006 on the implementation of the ISM Code within the Community

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 Part A of Annex I to Regulation (EC) No 336/2006)

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 Part A of Annex I to Regulation (EC) No 336/2006 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

Ro-ro passenger ship (ro-ro ferry)

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 and] (8) of Regulation (EC) No 336/2006 on the implementation of the ISM Code within the Community

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 (9): …

Gross tonnage: …

IMO Number: …

Name and address of Company: …

(see paragraph 1.1.2 of Part A of Annex I to Regulation (EC) No 336/2006)

THIS IS TO CERTIFY THAT the requirements of paragraph 14.4 of Part A of Annex I to Regulation (EC) No 336/2006 have been met and that the Document of Compliance/Interim Document of Compliance (10) 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 (10) 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)