Applicants name, address and telephone no.

: Form B 1

Builders certificate

Shipyard:
Name:
Port of registry:

Ship:

Building no.:
Year of build:
Type:
Name:
Port of registry:

Tonnage:

Gross tonnage:
Net tonnage:

Main dimensions:

Length: m
Breadth: m
Depth: m
Building material:

Hull: (If the hull is constructed at another shipyard, please insert the hull building no. at this shipyard and name and port
of registry of this shipyard here)
Building no.:
Name of shipyard:
Shipyard registered address:

Propulsion machinery:

Type, make:

Building sum:

Size of building sum:

S 547 / 00
Client:

Name and address of client:

The shipyard confirms to have built the ship to the above-mentioned client and to have
transferred the ownership to the client.
Date as well as the shipyards official stamp and signature(s):
(Please enclose documentation of the authority to sign the company)

We hereby confirm that the signature(s) of the shipyard is correct, that the date is correct, and that
the signatory/signatories is/are of full age and sound mind.

Name ______________________________ Name ______________________________

Position ______________________________ Position ______________________________

Address: ______________________________ Address ______________________________

All signatures that are not absolutely legible must also be given in block letters, by means of a stamp or in
typescript.