Declaration Form Dgs-01 (Page 2 of 2) in pdf

Annex to Form No. DGS/ISM - 01

(To be completed by authorised representatives of the owner / bareboat charterer and the company on first notification

and when reporting any changes thereafter)

ISM Code Ref.: 3.0

For and on behalf of the Owner / Bareboat Charterer:

For and on behalf of the Company:

I, the undersigned, hereby declare and state as below:

1) The owner / bareboat charterer has agreement with

1) The company has accepted the agreement with the

the company for the operations of the vessel and to

owner / bareboat charterer and undertake to carry

discharge

all

duties,

responsibilities

and

out all aspects of the operation of the vessel and

obligations of the owner / bareboat charterer, which

discharge all duties, responsibilities and obligations

fall within the scope of Chapter IX of the SOLAS,

of the owner / bareboat charterer, which fall within

1974 as amended and the ISM Code from the date

the scope of Chapter IX of the SOLAS, 1974 as

of the present declaration.

amended and the ISM Code from the date of the

present declaration.

2) The owner / bareboat charterer has read and

2) The company has received from the owner /

understood the ISM Code and the requirement of

bareboat charterer sufficient instructions, guidance,

the

D.G.

Shipping

the

development,

means and resources to the entire satisfaction of

implementation and certification of SMS issued by

the company and arrangements have been made

the D.G. Shipping.

which enable and will enable the company to carry

out and fulfil the duties, responsibilities and

obligations

which are hereby

accepted and

undertaken.

3) The owner / bareboat charterer accepts, agrees

3) The company accepts, agrees and undertakes to

and undertakes to be responsible for the company

be bound, as far as the operation of the vessel and

(named overleaf).

for any matter related thereto, by the applicable

rules and regulations of the D.G. Shipping.

4) The above information is true and I am duly

4) The company has read and understood the ISM

authorised to make this declaration for and on

Code and the requirements of the D.G. Shipping on

behalf of the owner / bareboat charterer.

the development, implementation and certification

of SMS issued by the D.G. Shipping.

5) The above information is true and correct and I am

duly authorised to make this declaration for and on

behalf of the company.

For and on behalf of the Owner / Bareboat Charterer:

For and on behalf of the Company.

Name:

Signature:

Place & Date:

Stamp:

DGS/ISM-01/Rev.01/ Dec’08

Declaration Form Dgs-01 Page 2

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