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