Annex III MODEL FOR PRACTICAL EXAMINATION CERTIFICATES

We, name of the examining body,

hereby certify with document number …that

1. 1..

   Current family name(s) of the holder

2. 2..

   Current first name(s) of the holder

1. 3a.

   Date of birth (dd/mm/yyyy)

1. 3b.

   Place of birth (city)

has passed the practical examination [for obtaining a certificate of qualification as a boatmaster] [and] [for a specific authorisation for sailing with the aid of radar]

on the simulator (name of the simulator), approved by (name of the competent authority).

Place and date of issue

Signature and stamp of the examining body