DECLARATION FORM

I, the undersigned, Master of the ......................................................................................................

(1) Certify that my ship satisfies the conditions laid in Part I Article 18 to 45 of the Navigation Regulations and that in particular, the engines and the steering gear are in good working order.

(2) I declare that my ship has, at the present time, the following defects in engines or steering gear.................................................................................................................................................

(3)I declare, also, that the wireless installations on my ship permit to transmit on the frequencies, in kHz :

                Telegraphy ............................................................................... kHz.

                Telephony   ............................................................................... kHz.

(4) I state also that my ship is/ is not fitted with a Rudder angle indicator and Engine R.P.M. indicator on the bridge in such a position that the pilot may read both without having to move away from his station, and that the Rudder angle indicator/ Engine R.P.M. indicator is/ are in good working condition.

I undertake to bring to the notice of the Suez Canal Authority, before my ship enters the Canal, any defects, not specified above, which may appear.

                Made at Port ................................................, the signature: