APPLICATION FORM FOR REGISTRATION OF SHIPS

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1 Page 1 of 7 APPLICATION FORM FOR REGISTRATION OF SHIPS TYPE OF REGISTRATION APPLIED FOR PROVISIONAL REGISTRATION SECTION I VESSEL PARTICULARS Sierra Leone Proposed Name of Vessel IMO Number Previous Name of Vessel Previous Flag Year Built Place of Construction Year of Conversion(If applicable) Nature of Operation Builder s Name NOTE: If she is a supply vessel, please provide a declaration of product. The product list shall be submitted by the owner, with the company stamp. Type of Vessel SECTION II STRUCTURE, DIMENSIONS, ENGINE AND PROPULSION DETAILS (Information should be based on TC certificate and CLASS certificate) Material of Hull Length (m) Deadweight Breadth (m) Gross Tonnage Number of Engines Type Power (Kw) Manufacturer Model Year Built of the Engine Depth (m) Net Tonnage Number of Cylinder per Motor

2 Page 2 of 7 SECTION III COMMUNICATION DETAILS Inmarsat Number Transmitters Radio Accounting Authority AA07 - STRATOS GLOBAL Radio Equipment Details Type or Description of the Equipment Category of Service (A1, A2, A3 or A4) A1 Frequencies VHF VHF DSC MF/HF Radiotelephony MF/HF DSC Radar Transponder (SART) EPIRB NAVTEX Receiver AIS Portable Two Way (VHF) Inmarsat-B Inmarsat-C Inmarsat Mini C (SSAS) Inmarsat D+ Inmarsat M Inmarsat MINI M Inmarsat F EGC Iridium Radar GPS/DGPS LRIT

3 Page 3 of 7 SECTION IV RESIDENT AGENT Vessel's Name By this application, the Owner(s) of the, IMO Number hereby appoints SHIP REGISTRATION BUREAU (SL) LIMITED of 30 Siaka Stevens Str., Freetown, Sierra Leone to act as his/her/their Resident Agent and perform various services including but not limited to the administration of any applications to the National Authorities for any administrative proceedings pertaining to the vessel to which end they shall be empowered to take all necessary steps before the said Authorities for the object stated, and to file applications,prepare descriptions, make protests and sworn declarations, enter appeals and objections, pay taxes, prove workings, withdraw applications, recover any sum of money, obtain evidence, receive documents, accept transfers, and do all and whatsoever shall be necessary before any judicial or administrative authorities, with power also to appoint a substitute hereunder, and again to revoke such substituted power. SECTION V OWNERSHIP Registered Owner s Name Owner s IMO Number Registered Owner s Address Phone Number Fax Number Entity Responsible for Operation/Management of Ship if Different from Owner Ship Manager s Name IMO Number Ship Manager s Address Phone Number Fax Number Operator s Name IMO Number Operator's Address Phone Number Fax Number

4 Page 4 of 7 SECTION VI CLASSIFICATION Present Class Society Proposed Recognised Organization Class Society or Organization performing/certification for ISM-DOC/SMC ISPS DOC/ISMC/ISSC SECTION VII MANNING PARTICULAR Trading Area of Vessel Type of Voyage (If it is Special Registration): SCRAP DELIVERY VOYAGE UNLIMITED LIMITED (other than Unlimited) Specify the Areas COASTAL<200 N.M Specify the Areas Is the Vessel specified for Unmanned Machinery Space Operations YES NO Proposed Number of Crew (As prescribed under the international convention on standards of training, certification and watch keeping as amended by resolution A1047(27) principle of safe manning) Operating Company Name (copy of the safety management certificate, shall be submitted if applicable) Deck According GT Engine According KW STCW REGULATION INDICATE THE QUANTITY OF EACH POSITION THAT WILL SERVE ON BOARD DECK DEPARTMENT ENGINE DEPARTMENT POSITION/REGULATION NUMBER OF PERSONS POSITION/REGULATION NUMBER OF PERSONS MASTER / II-2 CHIEF ENGINEER / III-2 MASTER / II-3 CHIEF ENGINEER / III-3 CHIEF MATE / II-2 2ND ENGINEER / III-2

5 Page 5 of 7 CHIEF MATE / II-3 DECK OFFICER / II-1 WATCHKEEPING RATING / II-4 DECK RATINGS 2ND ENGINEER / III-3 ENG. OFFICER / III-1 WATCHKEEPING ENG. RATING / III-4 ENGINE RATINGS GMDSS OPERATOR Others SHIP SECURITY OFFICER (SSO) TANKER FAMILIARIZATIONS COOK ELECTRICIAN / TECHNICIAN PASSANGER VESSEL SECTION VIII BAREBOAT CHARTER DETAILS Charterer s Name Charterer s Address /Phone / If Bareboat Out Name of Second Flag If Bareboat In Name of first flag SECTION IX MORTGAGE DETAILS Name and Address of Mortgage /Bank First Preferred Second Preferred Mortgage Amount Place of execution of Mortgage deed Discharge Amount of Mortgage Date of Maturity

6 Page 6 of 7 SECTION X ADDITIONAL AFFIDAVITS FOR REGISTRATION (Applicants should sign proper affidavit below according the type of registration) AFFIDAVIT FOR PERMANENT REGISTRATION This is to confirm that we as *Owner /Owner s Agent of the ship with IMO number do hereby guarantee to present all documents required for the issuance of the Permanent Registration into the Sierra Leone Maritime Administration within 180 days from the date of the Provisional Registration of the above mentioned ship. SIGNATURE OF APPLICANT: AFFIDAVIT FOR CERTIFICATE OF ENDORSEMENT COE This is to confirm that we as *Owner /Owner s Agent of the ship with IMO number do hereby guarantee to submit all seafarers documents required for the certificate of endorsement of the seafarers working on board of SL ship. We are aware that failure to present proper documentation of endorsement may incur in a fine if vessel is detained due to this reason. Vessel is not allowed to navigate without COE provisional. SIGNATURE OF APPLICANT: AFFIDAVIT FOR SPECIAL REGISTRATION This is to confirm that we as *Owner /Owner s Agent of the ship do hereby confirm that the above mentioned ship is : Destined for demolition in (country of destination) with IMO number A single voyage only to (intended destination port) We understand that the registration applied for is not renewable and is for the above stated purpose only. SIGNATURE OF APPLICANT: AFFIDAVIT FOR YACHT REGISTRATION This is to confirm that we as *Owner /Owner s Agent of the yacht, do hereby declare that the mentioned yacht will be exclusively engaged in non-commercial activities. SIGNATURE OF APPLICANT:

7 Page 7 of 7 SECTION XI OWNER DECLARATION I, (full name) Declare: 1. I am the owner referred to above /an authorized person on behalf of owner and duly authorized to make this declaration¹ 2. The above particulars of the ship are correct. 3. The ownership is evidenced by a Bill of Sale /other document, the original /certified copy of which is attached. 4. The owner referred above is /is not² the only person entitled to the legal and beneficial interest of the ship. 5. The owner is entitled to be registered as the Owner of the interest of the ship referred above; or The Owner consents to the demise charter of the ship in accordance with the attached charter agreement. The Following Declaration should be filled and signed by the Manager/Owner I declare that the information in and with this application is true and correct knowing that it is an offence to give a document containing information know is false or misleading in a material particular Name and Position of the Declarant Signature Date Place Notes: 1- If the declarant is a person on behalf of owner, attach POA. 2- If there are persons other than the transferee who are entitled to a legal or beneficial interest of the ship (e.g. mortgage), attach details.

Section A: Ship s Details

Section A: Ship s Details MSD/MRCS/004/2012 Application Form for a Ship Station Licence (applicable only to SOLAS ships) With regard to radiocommunications equipment, in terms of the Electronic Communications (Regulation) Act (Cap.399),