ࡱ> G Rnbjbj<ii2'2'2'2'2'F'F'F'8~'\'F'j(((((8$94X9$ˣœi2't9Z8@8t9t9œ2'2'((d+8Z<Z<Z<t92'(2'(Z<t9Z<Z<,sy(?:jvNcHNv:6yyH$2'D|D t9t9Z<t9t9t9t9t9œœ2<(t9t9t9t9t9t9t9t9t9t9t9t9t9t9t9t9b %: CHINA CLASSIFICATION SOCIETY REQUEST FOR SHIP CERTIFICATION We hereby request China Classification Society to carry out verification of the following vessel and to issue the relevant certificates according to the requirements of applicable Conventions and Codes. We agree to pay the verification fee, any travelling and other expenses occurring in connection with the verification as per the provisions of China Classification Society. During the verification, we promise to provide appropriate health and safety protection for attending auditors in accordance with the applicable mandatory requirements and the recommendations specified in the Health and Safety Protection Guideline for Client of this society. Ships NameCall signflagType of Ship*IMO. No.Port of registryGross tonnageCapacity of passengerDate of buildClassClass No.Category of Certification SMCInterim& Initial& intermediate& renewal& additional& ISSCInterim& Initial& intermediate& renewal& additional& MLCInterim& Initial& intermediate& renewal& additional& Category of Certificate Paper Certificate& E-Certificate & Paper + E Certificate& Remark: please find the flag state list who entrust to issue E-cert in CCS official website Audit placeAudit language Date of auditName of payerTax No. of registrySafety Management CompanyNameAddress of registryAddress of officeCompany identification number:Contact personMobile phoneFax.EmailDesignated E-mail Receiving E-CertificateMLC shipownerNameRegistered addressOffice addressCompany identification number:Contact personMobile phoneFax.EmailDesignated E-mail Receiving E-CertificateAgent informationContact personPhoneFax.EmailNotePlease complete the form accordingly as per the category of applied audit and attach the hard copy or electronic documents as below if applicable. 1. SMCCopy of DOC and SMCissued by other RO , Management Agreement (if applicable), internal audit plan(interim audit) the last class status ( Non CCS ship). 2. ISSCthe copy of ISSC and Approval for Ship Security Plan (issued by other RSO), Registry Certificate (interim audit), Continuous Synopsis Record (CSR), Security exercise or drill and internal audit plan (interim audit), the last class status (Non CCS ship)0 3. MLC: the copy of DMLC and MLC (issued by other RO), MLC Management Agreement (if applicable), Registry Certificate (interim inspection), Continuous Synopsis Record (CSR), the last class status ( Non CCS ship) * Type of ship: please insert the type as below: 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. If the ships type is more than one, please insert accordingly, such as Oil tanker/Chemical tanker, etc(/FG 6 9 Z d      , - C ¹¹¹°shP\h]CJH*PJaJhP\h> CJH*PJaJhP\hn|@CJPJaJ hP\hP\hP\h]CJPJaJhDh@PJhP\hEPJhP\h PJhP\hkPJhP\h4@5CJPJhP\hk5CJ hi-5CJhP\h4@5CJ$PJaJ$-(G $$Ifa$gd `gdD $ a$gd $a$gd4@  5))) $$Ifa$gd kd$$Ifl4sֈ )%330%44 laf4yt    $$4$Ifa$gd $$Ifa$gd   , - 5)) $$Ifa$gd]kd$$Ifl4^ֈ )%330%44 laf4yt - C D R S $$4$Ifa$gd] $$Ifa$gd] $$Ifa$C D R S T Z [ e f g h i      " $ < > @ D F T V X \ ` t v ߿Ҳ߿Ҳ߿Ҳ߿Ҳ߿ߠߍ߲ߍ߲ߍ߲$hP\hECJOJPJQJ^JaJ#hP\hECJPJaJmHnHuhP\haMCJPJaJ$hP\h4@CJOJPJQJ^JaJhP\h4@CJPJaJhP\hECJPJaJ hP\hP\hP\h]CJPJaJ7S T Z [ e 5))) $$Ifa$gd kdr$$Ifl4^ֈ )%330%44 laf4yt e f g h $$Ifa$gd $$Ifa$gd]h i 5)) $$Ifa$gd kd+$$Ifl4ֈ )%330%44 laf4yt   eYY $$Ifa$gd kd$$Ifl4F )%0%    44 laf4yt $Ifgd       ( 6 8 < @ P R V Z r t v z  ະn,hRw3hRw3B*CJOJPJQJaJo(ph$hRw3hRw3B*CJPJaJo(phhP\hRw3CJPJaJhRw3CJPJaJo(hRw3CJPJaJ hP\hP\#hP\hECJPJaJmHnHuhP\haMCJPJaJhP\hECJPJaJ$hP\hECJOJPJQJ^JaJ$  ( nbbY $Ifgd $$Ifa$gd kd$$Ifl4F )%0%    44 laf4yt  h"nbYY $IfgdM^ $$Ifa$gdRw3kd($$Ifl4F )%0%    44 laf4yt 026`bfh "$<>\b~ :<>dfh۵}pppppp}pppp}pp}pp}pp}pp}ppppp}ppphP\hRw3CJPJaJ hP\hRw3!hRw3ha%B*CJPJaJphha%B*CJPJaJo(phhRw3B*CJPJaJo(phhRw3CJOJPJQJaJo(,hRw3hRw3B*CJOJPJQJaJo(ph$hRw3hRw3B*CJPJaJo(ph!hRw3hRw3B*CJPJaJph,"$<>\b~uuuuuu $$Ifa$gd ~kd$$Ifl40)% 0%44 laf4yta%5))) $$Ifa$gd kdY$$Ifl4ֈ )%=30%44 laf4yt  OFF $$Ifa$kd $$Ifl4\)% 3! 0%44 laf4yt $$Ifa$gd  :xx $$Ifa$~kd$$Ifl40)% 0%44 laf4yt :<>dxx $$Ifa$~kdm$$Ifl4,0)% 0%44 laf4yt dfhul $$Ifa$ $$Ifa$gd]~kd$$Ifl40)% 0%44 laf4yt xllll $$Ifa$gd $$Ifa$~kd$$Ifl40)% 0%44 laf4yt^H?333 $$Ifa$gd $$Ifa$kdS $$Ifl4r N)%3y 0%44 laf4yt Z\^`|<>XZ\^hjvxz|$&(*46BDFtvxĽĽhJFCJPJaJhJFCJPJaJo(hP\hRw3h9 ,CJPJaJ hP\hJFhP\hJFCJPJaJh shRw3CJPJaJh shRw3CJPJaJo( hP\hRw3hP\hRw3CJPJaJ<\^<3 $$Ifa$kd $$Ifl4r N)%3y 0%44 laf4yt $$Ifa$gd ^`|neY $$Ifa$gd7 $$Ifa$kd $$Ifl4F)% T0%    44 laf4yte-ul $$Ifa$ $$Ifa$gd ~kd $$Ifl40)% 0%44 laf4yt ul $$Ifa$ $$Ifa$gd ~kd= $$Ifl4,0)% 0%44 laf4yt ui $$Ifa$gd^ $$Ifa$gd@~kd $$Ifl40)% 0%44 laf4yt <>XZuuuuu $$Ifa$gd ~kd $$Ifl40)% 0%44 laf4yt^Z\^hjvxH<<<<< $$Ifa$gd kd#$$Ifl4r _)%3 0%44 laf4yt xz|H<<< $$Ifa$gd kd$$Ifl4r _)%3 0%44 laf4yt $&nbVbbb $$Ifa$gd> $$Ifa$gd> kd$$Ifl4F)% T0%    44 laf4yte-&(*46BDH<<<<< $$Ifa$gd> kdk$$Ifl4r _)%3 0%44 laf4yt> DFxH??3 $$Ifa$gd $$Ifa$kd7$$Ifl4r _)%3 0%44 laf4yt  $j04@Z^`tvx1ACnddddddee޼ƼƼƱƼ޼ޢޏޏވ hP\hRw3$hP\hRw3CJOJPJQJ^JaJUhP\h7CJPJaJh.PCJPJaJo(h7CJPJaJh.PCJPJaJhP\hRw3CJPJaJo(hP\hRw3CJPJaJhJFCJPJaJo(hJFCJPJaJ2deeTeVee^UL@ $`a$gd4@ $1$a$gdRw3 $1$a$gdDikd$$Ifl4)%%0%44 laf4yt $$Ifa$gdn4$U$IfWD^`Ua$gd.P$U$IfWD^`Ua$gd . if the ship belongs to Other cargo ship, please describe the specific type as classification certificate. * &Applicable &Not ApplicableRev. 2018070120230601-1/2 CHINA CLASSIFICATION SOCIETY REQUEST FOR SHIP CERTIFICATION The reason for applying an additional audit/inspectionif applicable The status of PSC/FSC since last external audit. Including the date, place, quantity of deficiency and rectification The current version of SMS, SSP and DMLC PART II and the major revision: The version of SMS Management documentManual_____________, Effective Date______________. The version of SSP_____________, Effective Date ______________. The version of DMLC Part II_____________, Effective Date ______________. & The SMS has been implemented on board at least three months and an internal audit has been carried out for SMS (apply to initial audit for SMC) & The DMLC Part II has been implemented on board at least one month (apply to initial inspection for MLC) & All crew members will be changed at the port where the audit will be conducted. The major revision of SMS, SSP and DMLC-II since last external audit/inspection (if applicable). 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