Международное свидетельство об изъятии для грузовой марки (англ.)

Annex III

            INTERNATIONAL LOAD LINE EXEMPTION CERTIFICATE

     (Official seal)

     Issued  under  the  provisions of the International Convention on

Load lines, 1966, under the authority of the Government of

______________________________________________________________________

             (full official designation of the country)

by____________________________________________________________________

 (full official designation of the competent person or organization

                           duly authorized

______________________________________________________________________

       under the provisions of the International Convention on

                          Load Lines, 1966)

------------------------T-------------------------T------------------¬

¦  Name of Ship         ¦Distinctive Number or    ¦Port of           ¦

¦                       ¦Letters                  ¦Registry          ¦

+-----------------------+-------------------------+------------------+

¦                       ¦                         ¦                  ¦

¦                       ¦                         ¦                  ¦

L-----------------------+-------------------------+-------------------

     This is to certify that the above-mentioned ship is exempted from

the  provisions of the 1966 Convention,  under the authority conferred

by  Article  6 (2)  Article  6 (4)  <*>  of the Convention referred to

above.

     The  provisions of the Convention from which the ship is exempted

under Article 6 (2) are:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

     The  voyage  for  which exemption is granted under Article 6  (4)

is:

From: ________________________________________________________________

To: __________________________________________________________________

     Conditions,  if  any,  on  which  the  exemption is granted under

either Article 6 (2) or Article 6 (4):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

     --------------------------------

     <*> Delete whichever is inapplicable.

     This  certificate  is  valid  until _____________________________

subject,  where  appropriate,  to periodical inspections in accordance

with Article 14 (1) (с) of the Convention.

Issued at ____________________________________________________________

                     (Place of issue of certificate)

____________19___

(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

Government to issue this certificate.

                                               _______________________

                                                   (Signature)

                       Reverse of Certificate

     This  is  to  certify that this ship continues to comply with the

conditions under which this exemption was granted.

     Place ______________________________ Date _______________________

     Signature and/or Seal of issuing authority.

     Place ______________________________ Date _______________________

     Signature and/or Seal of issuing authority.

     Place ______________________________ Date _______________________

     Signature and/or Seal of issuing authority.

     Place ______________________________ Date _______________________

     Signature and/or Seal of issuing authority.

     This  ship  continues  to  comply with the conditions under which

this exemption was granted and the validity of this certificate is, in

accordance  with Article 19 (2) (a) of the Convention,  extended until

_____________________

     Place ______________________________ Date _______________________

     Signature and/or Seal of issuing authority.