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 ship 
                                       
                                       
                                    
                                    
                                       - 
                                          Name of ship .................................................................................. 
- 
                                          Distinctive number or letters ........................................................
                                              
- 
                                          Port of registry .............................................................................. 
- 
                                          Gross Tonnage ............................................................................... 
- 
                                          IMO number ...............................................................................  
- 
                                          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) (dd/mm/yyyy) ......
                                    
                                    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 
- 
                                          □ other approach in accordance with regulation ...... 
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)
                                       
                                    
                                    Endorsement for annual and intermediate survey(s) 
                                    
                                    This is to certify that at a survey required by regulation E-1 of the Annex to the
                                       Convention the ship was found to comply with the relevant provisions of the Convention:
                                    
                                    
                                       
                                          
                                             
                                             
                                                
                                                | Annual survey:  | Signed ...................................................  | 
                                             
                                             
                                                
                                                |  | 
                                                      (Signature of duly authorized official) 
                                                       | 
                                             
                                             
                                                
                                                |  |  Place ..................................................... | 
                                             
                                             
                                                
                                                |  |  Date ...................................................... | 
                                             
                                             
                                                
                                                |  | 
                                                      (Seal or stamp of the authority, as appropriate)
                                                       | 
                                             
                                             
                                                
                                                | Annual*/Intermediate survey*: |  Signed ................................................. | 
                                             
                                             
                                                
                                                |  | 
                                                      (Signature of duly authorized official) 
                                                       | 
                                             
                                             
                                                
                                                |  |  Place ..................................................... | 
                                             
                                             
                                                
                                                |  |  Date ...................................................... | 
                                             
                                             
                                                
                                                |  | 
                                                      (Seal or stamp of the authority, as appropriate) 
                                                       | 
                                             
                                             
                                                
                                                |  Annual*/Intermediate survey*:  | Signed ................................................. | 
                                             
                                             
                                                
                                                |  | 
                                                      (Signature of duly authorized official)
                                                       | 
                                             
                                             
                                                
                                                |  | Place ................................................... | 
                                             
                                             
                                                
                                                |  | Date .................................................... | 
                                             
                                             
                                                
                                                |  | 
                                                      (Seal or stamp of the authority, as appropriate) 
                                                       | 
                                             
                                             
                                                
                                                |  Annual survey:  | Signed .................................................  | 
                                             
                                             
                                                
                                                |  | 
                                                      (Signature of duly authorized official)
                                                       | 
                                             
                                             
                                                
                                                |  | Place ................................................... | 
                                             
                                             
                                                
                                                |  | Date .................................................... | 
                                             
                                             
                                                
                                                |  | 
                                                      (Seal or stamp of the authority, as appropriate)
                                                       | 
                                             
                                       
                                     
                                    
                                    * Delete as appropriate 
                                    
                                    Annual / intermediate survey in accordance with regulation E-5.8.3 
                                    
                                    THIS IS TO CERTIFY that, at an annual / intermediate survey in accordance with regulation E-5.8.3 of the Annex to the Convention, the
                                       ship was found to comply with the relevant provisions of the Convention:
                                    
                                    Signed .................................................
                                    
                                    
                                       (Signature of authorized official) 
                                       
                                    
                                     Place ................................................... 
                                    
                                     Date .................................................... 
                                    
                                    
                                       (Seal or stamp of the authority, as appropriate) 
                                       
                                    
                                    Endorsement to extend the certificate if valid for less than 5 years where regulation
                                       E-5.3 applies 
                                    
                                    The ship complies with the relevant provisions of the Convention, and this Certificate
                                       shall, in accordance with regulation E-5.3 of the Annex to the Convention, be accepted
                                       as valid until ...........................................
                                    
                                    Signed .................................................
                                    
                                    
                                       (Signature of authorized official) 
                                       
                                    
                                     Place ................................................... 
                                    
                                     Date .................................................... 
                                    
                                    
                                       (Seal or stamp of the authority, as appropriate) 
                                       
                                    
                                    Endorsement where the renewal survey has been completed and regulation E-5.4 applies
                                       
                                    
                                    The ship complies with the relevant provisions of the Convention and this Certificate
                                       shall, in accordance with regulation E-5.4 of the Annex to the Convention, be accepted
                                       as valid until ..........................................
                                    
                                    Signed .................................................
                                    
                                    
                                       (Signature of authorized official) 
                                       
                                    
                                     Place ................................................... 
                                    
                                     Date ....................................................
                                    
                                    
                                       (Seal or stamp of the authority, as appropriate) 
                                       
                                    
                                    Endorsement to extend the validity of the certificate until reaching the port of survey
                                       or for a period of grace where regulation e-5.5 Or E-5.6 applies 
                                    
                                    This Certificate shall, in accordance with regulation E-5.5 or E-5.6 of the Annex to the Convention, be accepted as valid until ...........
                                    
                                    Signed .................................................
                                    
                                    
                                       (Signature of authorized official) 
                                       
                                    
                                     Place ...................................................
                                    
                                     Date ....................................................
                                    
                                    
                                       (Seal or stamp of the authority, as appropriate) 
                                       
                                    
                                    Endorsement for advancement of anniversary date where regulation E-5.8 applies 
                                    
                                    In accordance with regulation E-5.8 of the Annex to the Convention the new Anniversary
                                       date is .............
                                    
                                    Signed .................................................
                                    
                                    
                                       (Signature of authorized official) 
                                       
                                    
                                     Place ...................................................
                                    
                                     Date .................................................... 
                                    
                                    
                                       (Seal or stamp of the authority, as appropriate) 
                                       
                                    
                                    In accordance with regulation E-5.8 of the Annex to the Convention the new Anniversary
                                       date is .....................
                                    
                                    Signed .................................................
                                    
                                    
                                       (Signature of duly authorized official) 
                                       
                                    
                                     Place ...................................................
                                    
                                     Date 
                                    
                                    
                                       (Seal or stamp of the authority, as appropriate)