Division DOCUMENT OF COMPLIANCEF1

(Official seal)/(State)

Certificate No

Issued under the provisions of [the INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974, as amended and] ^f1 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)