APPLICATION FOR EXEMPTION FROM REGULATIONS

NOTES:

a)This form may take you 5 minutes to fill in. You will need the following information to fill in the form:

a) Ship’s particulars & b) Details of certificate concerned.

b)Please complete the application form and submit itthrough the Classification Societyto Flag State Control Department, Maritime and Port Authority of Singapore(email: / Fax No: 65-6375 6231).

c)Please enclose a copy of the relevant certificates or documents, which requires exemption.

d)Please submit the application for extension at least 5 working days before the expiry of the certificate.

e)Please note that processing time is normally within 3 working days.

1. / Name of Vessel: / 2. / Ship Type:
3. / Gross Tonnage: / 4. / IMO Number:
5. / Keel Laid Date: / 6. / Official Number:
7. / Classification Society:
  1. Type of voyageas specified in the certificate(e.g. international, short international, 30-mile limit, etc.):
  1. The relevant main certificate for which the exemption is required (e.g. Cargo Ship Safety Equipment):
  1. The classification society which will issue the main certificate and the expected expiry date of the main certificate, if available:
  1. Reference of regulation(s) from which exemption is required (title of regulation or convention, chapter, regulation number):
  1. Reasons for requesting the exemption:
  1. The provision in the regulations which allows exemption to be granted:
  1. Actual situation of the ship, conditions to be imposed or alternative arrangement proposed:
  1. Copy of exemption certificate or letter of approval issued by the previous flag Administration (This applies to application for an exemption which was granted by the previous flag Administration)
  1. Other comments / information:

PARTICULARS OF APPLICANT

Name:

Owner / Company / Agent*:

Telephone No.: Fax No.: Email:

Date:

* Delete as appropriatewef 30 July2012