DECLARATION "A"
| Date | .................... |
| Master | .................... |
| Vessel’s Name | ................................................................................ |
| Vessel’s Name | ................................................................................ |
| Vessel’s Owner | ................................................................................ |
| Address | ................................................................................ |
| Vessel’s Operator | ................................................................................ |
| Address | ................................................................................ |
| Agent | ................................................................................ |
| DOCUMENT | ISSUING AGENCY | ISSUE DATE | EXIPARTION DATE |
| IMO Certificate | |||
| Classification Society Certification | |||
| Safety Equipment Certificate | |||
| Safety Construction Certificate | |||
| Safety Radio Telegraph Certificate | |||
| Other Safety Inspections |
Master’s Signature : ........................................................