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)

----------------------------------------------------------------------
¦  Name of Ship         ¦Distinctive Number or    ¦Port of           ¦
¦                       ¦Letters                  ¦Registry          ¦
+-----------------------+-------------------------+------------------+
¦                       ¦                         ¦                  ¦
¦                       ¦                         ¦                  ¦
------------------------+-------------------------+-------------------

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)   1   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):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

--------------------------------
1  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.

Источник - Международная конвенция от 05.04.1966