Exemption request form - maritime rules - Maritime New Zealand

ASSESSMENT OF SAFETY RISKTaking into account the purpose of the rule, explain how, in this case, and given any action taken or provision made, therisk to safety is not significantly increased (if necessary, continue on an attached sheet).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PAYMENT METHODI am paying my $581.00 application fee by:Credit Card (attach credit card form)Cheque made out to Maritime New ZealandBank transfer to Maritime New Zealand account 03-0558-0142032-00Vessel name, MNZ/MSA number and the word Exemption (ex: Maritime MNZ# 100000 EXEMPTION) must be includedin the payment reference. A further fee may be charged if an exemption request is approved but requires more technicaland management input. These additional costs will be invoiced upon the certificate being issued.DECLARATIONI hereby confirm that the vessel complies, or will comply, with all other relevant maritime and marine protection rules andthat the risk to safety will not be significantly increased by the granting of this exemption. I also understand that, to myknowledge, this exemption does not breach New Zealand's obligations under any international convention.Signed: (Owner or Operator)________________________________________________________________________________________________Signed: (Surveyor)________________________________________________________________________________________________Endorsed by SSM Company:________________________________________________________________________________________________Version 5 – February 2012 4 of 4