MSN 05/2008

JABATAN LAUT MALAYSIA

MARINE DEPARTMENT MALAYSIA

MALAYSIAN SHIPPING NOTICE

Marine Department HQ, Peninsular Malaysia, PO. Box 12, 42007 Port Klang, Malaysia.
Tel: 03 33467777 Fax: 03 31685020 E-mail: kpgr@marine.gov.my Web site: http://www.marine.gov.my

Notis kepada pemilik kapal serta orang yang mempunyai kepentingan kepada kebenaran
pengeluaran sijil-sijil statutory.
Notice to ship owners and persons with interest toward the delegation of statutory certification.

APPLICATION FORM
FOR THE EXEMPTION / EXTENSION
OF AN INTERNATIONAL CONVENTION REQUIREMENT

For application of short term, extensions and exemption certificates, ship owners, managers, and
agent are advised to submit form attached in appendix 1 with supporting documents and class
recommendations.

For exemptions of items required under relevant conventions such as non compliance or
malfunction of Navigation, Radio equipments, LSA and FFA equipments or non availabilities
approved servicing and testing or spare parts. RO is allowed to issue exemption certificate or short
term certificate for period not more than 3 months provided the application of exemption shall be
submitted immediately but not later than 2 weeks from issuance of such certificates.

For Extensions of statutory certificates the application shall be submitted 1 months prior the expiry
of such certificates.

Ketua Pengarah Laut/ Director General of Marine

Tarikh/Date: 24 DECEMBER 2008
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APPLICATION FOR THE EXEMPTION FROM AND EXTENSION

OF AN INTERNATIONAL CONVENTION REQUIREMENT

To: Surveyor General of Ships

Marine Department of Malaysia

Particulars of ship:
Name of Ship: Distinctive number or letters: Gross Tonnage:

Owner/Agent: Port of Registry: IMO Number:

Details of Certificate(s) required:

Exempted from the requirements Conferred by the Regulations of:
of :

Reason(s) to support the application:

Exemption Certificate:

Duration Requested:

Type of certificate to be extended:

Extension for Docking Reason(s) to support the application:

Survey/Special Survey or Statutory
Certificate:

Duration Requested:

Safety Measure taken:

 MSN 05/2008

Classification Society recommendations related to this application:

Declaration by the Operator/Charterer/Owner of Vessel:

I/we*, the undersigned, hereby declare that the above mentioned vessel has not been subjected to any accident or
other occurrence which would raise any doubt as to the vessel continuing to be seaworthy and that she is properly
equipped to operate within the limits prescribed in the said Certificate.

…………………… ……...……………………………..
(date) (Operator/Charterer/Owner of Vessel)

Flag State (Malaysia) remarks related to this application:

…………………… ……...……………………………..
(date) ( )