KS-0103E KOI Rev.: 01.10.2016 Page 1 of 8

Form KS-0103 Declaration of the company’s control shall be submitted upon request for annual, intermediate and renewal survey for:

Passenger Certificate;

Cargo Ship Trading Certificate;

Trading Certificate of Compliance for Fishing Vessel.

For ships with Passenger Ship Safety Certificate in domestic trade (EU), use instead form «KS-0855 Rederiets egenkontroll ved fornyelse av Sikkerhetssertifikat for passasjerskip i innenriks fart».

Call sign

Name of ship

The declaration shall be submitted in connection with Form No. KS-0115 Request for survey. If the company’s control is not completed when the request for survey is submitted, the declaration shall be forwarded as soon as the company’s control has been completed.

The Norwegian Maritime Authority (NMA) must have received the declaration before the survey can take place.

For the items 102-106 concerning hull with accessories, the NMA accepts that the items remain open until this can be checked in dock/on slipway/during diving examination. When the company’s control of hull with accessories are completed, a new declaration or updated declaration shall be submitted to the NMA or be delivered to the NMA’s inspector.

Please submit the declaration one of the stated ways: by e-mail to post@sdir.no, by mail to Norwegian Maritime Authority, Box 2222, NO-5509 Haugesund, Norway,

submitted to one of the NMA’s local offices.

Responsibility and duties of company/master

The company is responsible for establishing routines ensuring that all vessel items subject to control are in satisfactory condition and in compliance with regulatory provisions, cf. chapter 2 of the Ship Safety and Security Act. The master is responsible for the compliance with applicable provisions on board, cf. chapter 2 and sections 19, 29, 37 and 45 of the Ship Safety and Security Act. It is the duty of the company, or the person acting on behalf of the company to carry out the company’s control and to submit this declaration duly completed before the survey can take place. Cf. sections 21 (2), 25 (3) and 27 (3) in Regulations of 22 December 2014 No. 1893 on supervision and certificates for Norwegian ships and mobile offshore units. The company’s control shall be completed within the time window applicable to the survey in question. All items in the declaration applicable to the vessel must be addressed.

Declaration of

the company’s control

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 2 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

100* Hull with accessories Docking interval according to sections 21 81), 25 (1) and 27 81) in Regulations of 22 December 2014 No. 1893

102 Hull, outside Damage, cracks, corrosions, thickness measurement Date of last docking:

103 Bottom and over-board valves Corrosions, cracks, closing devices

104 Helm Damage, cracks, corrosions, wear, leakage. Measuring clearances

105 Propeller Damage (unbalance), cracks, play, cavitations, leakage

106 Propeller shaft Wear, corrosions, cracks, leakage in tightening arrangement for casing. Measuring clearances

107 Ports/hatches in bow, sides and stern Damage, cracks, leakage, weather tightness, effective closing, instructions for use. Function test.

108 Anchor and mooring goods, towing equipment Damage, wear, corrosions. Function test. Date of annual survey of tug/anchor-handling equipment:

109 Hull, inside Damage, cracks, corrosions, thickness measurement

110 Water tightness Water tightness of collision bulkhead, doors, hatches, dampers. Function test

111 Tanks Damage, corrosions, cracks, coating. Pressure testing

200* Machinery To be tested according to working time recommended by producer, when working time can be measured on board

202 Main engine Updated maintenance system, engine log

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 3 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

203 Exhaust installation Leakage, insulation

204 Gear Function test

205 Coupling Function test

206 Servo installation Function test

207 Auxiliary engine Test running/ full load testing

208 Pumps (fuel oil, cooling water, lube oil) Function test

209 Compressors Function test

210 Starting system incl. starting air tanks Function test

211 Boilers Corrosions, leakage, safety automatics

212 Coolers/heat exchangers

213 Bilge and ballast system Function test. Tightness, indicators, valves, pumps

214 Arrangement for fuel oil and other oil installations

Corrosions, leakage, insulation, fire safety (shielding), quick-closing valves, remote stop

215 Electrical installation Declaration from DBS (o/50V), and/or valid installation certificate from electrical installation enterprise (u/50V). Check cleanliness.

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 4 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

216 Emergency source of power Function test, capacity, emergency lighting

217 Safety measures and cleanliness of engine- room

Cleanliness, emergency exits, screening, self-closing valves

218 Steering gear, emergency steering Function test. Leakage, alarms, instructions

219 Communication for maneuvering Audibleness

220 Operational arrangements Self-steering system, alarms

* Classed cargo ships, barges and fishing vessels are not required to fill out the items under 100 and 200.

300 Load line conditions

303 Closing arrangements and drainage Damage, corrosions, tightness, blind cover, freeing ports, freeing flaps. Function test

400 Fire-fighting appliances

402 Fire control plans Approved, posted up, readable, correct

403 Main fire extinguishing system Fan stop, alarms. Measuring of gas amount and obligatory survey by specialist. Date of last survey:

404 Water spray system on car deck Pump capacity, nozzles, drainage, emergency power

405 Fire pumps with equipment Pressure and suction capability, fire main, hydrant, valves, fire hoses, international connection, keys for coupling

406 Ventilation, dampers, doors/fire doors Closure/shut-down system, condition, marking

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 5 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

407 Fire detection and fire alarm system Manual and automatic functioning

408 Fire extinguishers Annual survey and internal control Date of last annual survey:

409 Fireman’s outfit, compressed-air apparatus

Monthly survey. Annual survey/ 5-year pressure testing of compressed-air apparatus.

Date of last a. survey/5-year test :

500 Cargo-handling equipment

502 Cargo-handling equipment, including trawl winch, seine drum, power block

Control book, drawings and certificates on board, safety arrangements, arrangements for maneuvering and marking, function testing, included decks/ramp capable of being hoisted (competent person).

Date of last annual/5-year survey:

600 Pollution

602 Oil pollution Valid IOPP certificate, equipment for collecting oil, oil-water separating equipment, oil record book

603 Garbage pollution Entered in deck log, agreements with port authorities, notices

604 Discharge of garbage and cargo residues Duty to notify

605 Noxious liquid substances in bulk Valid certificate, cargo record book

606 Air pollution Valid certificate, amendments

607 Anti-fouling systems Valid certificate, amendments

608 Sewage pollution Valid certificate, amendments

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 6 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

700 Safety measures

702 Means of access Gangway, ladders, railing, net, ferry side, pilot hoist and pilot ladder

703 Personnel lift, combined goods /pers. lift Valid lift certificate. Date of last survey:

704 Protective measures Securing of movable parts, emerg. stop devices, personal protection/safety

705 Other safety measures Signs at radar, noise, storage of combustibles, particularly dangerous substances, electrical board area, free escape routes, securing of cargo. Function test of alarms for hatches and bilge sump, monitoring of hatches

706 Welding Damage, location of gas cylinders, marking. Valid installation certificate for welding central.

Date of last survey:

707 Ventilation of cargo spaces, tanks, tunnels Measuring instruments, marking, approved lighting

708 Gas-fired installations Damage, leakage. Valid install. certificate. Date of last survey:

709 Dangerous cargo Extra fire and safety equipment, stowage plan, marking

710 Diving system Valid certificate for diving system.

800 Manning, protection and environment

801 Manning, qualifications, conditions of employment, safety training, hours of rest.

Manned acc. to minimum safe manning document, valid personal certificates, incl. radio operator’s certificate, employment agreements, medical certificates, course certificates, provisions on hours of rest.

804 Working environment, health and safety Risk assessment, training, protective equipment, report of personal injuries, safety representative.

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 7 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

900 Accommodation and catering

902 Accommodation Ventilation, lighting/emerg. lighting, heating, exits/means of escape

903 Catering Cleanliness, wear, dishwasher, potable water, freezer temperature

1000 Life-saving appliances

1002 Lifeboats, pick-up boats, rescue boats, work boats

Condition, instructions, floating appliances, equipment, marking, engine and fuel tank

1003 Inflatable life rafts Annual service of rafts, annual service and correct mounting of hydrostatic releasers, instructions.

Date of raft service:

1004 Launching arrangement for boats and rafts Brakes, hooks, wire fall and changing. Function test. Date of last change of wire:

1005 Embarkation arrangement Means of access, ladders, emergency lighting, evacuation chute, annual service of evacuation slide, mounting instructions

1006 Personal life-saving appliances Approved, condition, number of lifebuoys, lifejackets, immersion suits

1007 Line-throwing appliances Number: Not valid after:

1008 Distress signal light Number: Not valid after:

1009 Muster list, emergency instructions Approved, posted-up, correct

1010 Alarm system Audibleness

1011 Lifeboat and fire drills Drills conducted according to the regulations. Date of last drill:

Norwegian Maritime Authority Declaration of the company’s control

1)Fill out as follows: X = in order I = not applicable U=under repair KS-0103E KOI Rev.: 01.10.2016 Page 8 of 8

Call sign: Name of ship:

No. Area for inspection

Co

de

1)

Pay special attention to: Comments:

1012 Equipment for internal communications Audibleness

1013 Radio life-saving appliances Two-way radiotelephone apparatus, radar transponders. Annual survey, function test

1100 Navigational aids and radio

1102 Navigational aids (compass, radar, steering gear, indicators, bridge watch alarm, lights, distress signal, etc.)

Approved, function test, connection to emergency source of power. Updated charts and other publications. Spare parts.

1103 Radio Function test. Float-free EPIRBs, manual EPIRBs. Date of last radio survey:

1200 Ship’s documents

1201 Certificates and permits, etc. Valid certificates, approved documentation of stability and other relevant documents on board

1202 Statutory instruments, etc. Relevant legislation for the type of ship and first-aid book on board

1203 Logbooks and other records Logbooks appropriate to the size of ship and medicine control book on board

• Upon review of the check list, the company/master is responsible for immediately carrying out necessary repairs when defects or deficiencies are discovered.

• Words in italics refer especially to fishing vessels.

Additional information, if any:

We hereby declare that the vessel complies with regulatory provisions, and that it is ready for survey.

Date

Company’s/master’s signature