APPENDIX I
FORM OF INTERNATIONAL BALLAST WATER MANAGEMENT CERTIFICATE
INTERNATIONAL BALLAST WATER MANAGEMENT CERTIFICATE
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 ship1
Name of ship ……………………………………………………………………………………………..
Distinctive number or letters ………………………………………………………………………..
Port of registry …………………………………………………………………………………………..
Gross Tonnage …………………………………………………………………………………………..
IMO number2 …………………………………………………………………………………………….
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) ………………………………………………………………………..
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
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)
