中 国 船 级 社 CHINA CLASSIFICATION SOCIETY

注 Notes:

X 适用 Applicable 不适用 Not Applicable 中 国 船 级 社

CHINA CLASSIFICATION SOCIETY

营运检验申请

APPLICATION FOR SURVEYS AND ISSUE OF

CERTIFICATES OF SHIP IN SERVICE

No.

下面署名申请人/公司申请中国船级社对船舶/设施进行检验和发证，申请人/公司承诺提供有关图纸资料和检验条件以及

负担检验费和相关费用。

The undersigned requests CHINA CLASSIFICATION SOCIETY to carry out survey(s)/ to issue certificate(s) for the ship below and installations and the undersigned promises to provide drawings/survey condition and bear all survey fee and expenses involved. 船名

Name of ship 船级登记号 CCS No. 船旗 Flag

船舶种类 Type of ship 检验地点

Place of survey

检验日期 Date of survey

申请人/公司Applicant 邮编

Post Code 船东或管理人 邮寄证书地址

*Address of Owners or Operators for Cert. Mailing 电话 TEL

传真 FAX No.

联系人

Contact with

代理名址 Agency

电话 TEL 传真 FAX No. 联系人

Contact with

*为了您的方便, 请认真填写完整地址以便证书准确地寄送

For your convenience, please fill with full address to ensure the certificates to be properly mailed to your company. 检验种类Kind of Survey(s):

A. 船级检验CLASS SURVEYS 特别检验（船体/轮机）（开始/进行中/完成）* Special survey （H/M ）(Commenced/incompleted/Completed)* 尾轴和螺旋桨轴检验（部分/变通）* Screwshaft and Tube Shaft Survey(Partial/Modified)* 冷藏装置特别检验 Special survey for Refrigerated Cargo Installation 锅炉检验 Boiler Survey 年度检验(船体/轮机/冷藏)* Annual Survey(H/M/R)* 修理/改装*检验 Repair/Alteration* Survey 中间检验（(船体/轮机/冷藏)）* Intermediate Survey(H/M/R)* 临时检验 Occasional Survey 循环检验（轮机/冷藏）* Continuous Survey(M/R)* 展期检验 Postponement Survey for 坞检/水下检验 Docking/Inwater* Survey 其他： Others: *不适用者划去Delete as appropriate

B. 法定检验STATUTORY SURVEYS 载重线LL 构造SC 设备 SE 无线电SR 客船 PSS 防油污IOPP 生活污水 ISPP 大气污染 IAPP

初次Initial □ □ □ □ □ □ □ □ □ □ 换新Renewal □ □ □ □ □ □ □ □ □ □ 期间Intermediate □ □ □ □ □ 定期Periodical □ □ □ □ □ 年度Annual □ □ □ □ □ □ □ 附加Additional □ □ □ □ □ □ □ □ □ □ C. 起货设备CARGO GEAR SURVEY(S)

四年度Quadrennial 年度/年度全面AI/ATE 临时Occasional 吊重Load Test 付款方式Form of Payment 现金Cash 支票Cheque

银行转账Through Bank

申请人签名/盖章

Applicant’s Signature and Stamp

日期 Date

（Rev4.1 20061201 1/1）