Issued under the provisions of the International Convention for the Control and Management of Ships' Ballast Water and Sediments (hereinafter referred to as “the Convention”) under the authority of the Government of

.................................................................................................................

(full designation of the country)

by ...........................................................................................................

(full designation of the competent person or organization authorized under the provisions of the Convention)

Particulars of ship

1) Alternatively, the particulars of the ship may be placed horizontally in boxes.

Name of ship ..................................................................................

Distinctive number or letters ........................................................

Port of registry ..............................................................................

Gross Tonnage ...............................................................................

IMO number

2) IMO Ship Identification Number Scheme adopted by the Organization by resolution A.1117(30), as may be amended.

...............................................................................

Date of Construction .....................................................................

Ballast Water Capacity (in cubic metres) .....................................

Details of Ballast Water Management Method(s) Used

Method of ballast water management used ......

Date installed (if applicable) (dd/mm/yyyy) ......

Name of manufacturer (if applicable) ......

The principal ballast water management method(s) employed on this ship is/are:

□ in accordance with regulation D-1

□ in accordance with regulation D-2 (describe) .....

□ the ship is subject to regulation D-4

□ other approach in accordance with regulation ......

This is to certify:

1. That the ship has been surveyed in accordance with regulation E-1 of the Annex to the Convention; and

2. That the survey shows that Ballast Water Management on the ship complies with the Annex to the Convention.

This certificate is valid until ............. subject to surveys in accordance with regulation E-1 of the Annex to the Convention.

Completion date of the survey on which this certificate is based: dd/mm/yyyy

Issued at

(Place of issue of certificate)

.................................... ...............................................................

(Date of issue) Signature of authorized official issuing the certificate)

(Seal or stamp of the authority, as appropriate)

Endorsement for annual and intermediate survey(s)

This is to certify that at a survey required by regulation E-1 of the Annex to the Convention the ship was found to comply with the relevant provisions of the Convention:

Annual survey: | Signed ...................................................

(Signature of duly authorized official)

Place .....................................................

Date ......................................................

(Seal or stamp of the authority, as appropriate)

Annual*/Intermediate survey*: | Signed .................................................

(Signature of duly authorized official)

Place .....................................................

Date ......................................................

(Seal or stamp of the authority, as appropriate)

Annual*/Intermediate survey*: | Signed .................................................

(Signature of duly authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

Annual survey: | Signed .................................................

(Signature of duly authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

* Delete as appropriate

Annual / intermediate survey in accordance with regulation E-5.8.3

THIS IS TO CERTIFY that, at an annual / intermediate

** Delete as appropriate

survey in accordance with regulation E-5.8.3 of the Annex to the Convention, the ship was found to comply with the relevant provisions of the Convention:

Signed .................................................

(Signature of authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

Endorsement to extend the certificate if valid for less than 5 years where regulation E-5.3 applies

The ship complies with the relevant provisions of the Convention, and this Certificate shall, in accordance with regulation E-5.3 of the Annex to the Convention, be accepted as valid until ...........................................

Signed .................................................

(Signature of authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

Endorsement where the renewal survey has been completed and regulation E-5.4 applies

The ship complies with the relevant provisions of the Convention and this Certificate shall, in accordance with regulation E-5.4 of the Annex to the Convention, be accepted as valid until ..........................................

Signed .................................................

(Signature of authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

Endorsement to extend the validity of the certificate until reaching the port of survey or for a period of grace where regulation e-5.5 Or E-5.6 applies

This Certificate shall, in accordance with regulation E-5.5 or E-5.6

* Delete as appropriate

of the Annex to the Convention, be accepted as valid until ...........

Signed .................................................

(Signature of authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

Endorsement for advancement of anniversary date where regulation E-5.8 applies

In accordance with regulation E-5.8 of the Annex to the Convention the new Anniversary date is .............

Signed .................................................

(Signature of authorized official)

Place ...................................................

Date ....................................................

(Seal or stamp of the authority, as appropriate)

In accordance with regulation E-5.8 of the Annex to the Convention the new Anniversary date is .....................

Signed .................................................

(Signature of duly authorized official)

Place ...................................................

Date

(Seal or stamp of the authority, as appropriate)