Application for Admission to navigate in the Northern Sea Route Area (NSRA)

(to be sent to the Northern Sea Route Administration by email in pdf format)

___________________ ________ (Date, Month, Year)

1 Details of !essel
1 " !essel(s) name(s) #ype of $essel

" Appli%ant status

(ti%& bo') Ship o3ner4s representati$e Ship Master

Ship o3ner

( Details of Appli%ant ( 1 )illed by le*al entities only

)ull name of or*ani+ation ,M- number (if a$ailable) Surname, )irst name, .atronymi% (if a$ailable) of the /ead 0onta%t telephone, )a', 12mail

( " )illed by indi$iduals only

Surname, )irst name, .atronymi% (if a$ailable) of the Appli%ant

" 0onta%t telephone, )a', 12mail

Prior to entering the NSRA the Ship owner undertakes to provide the vessels compliance with the Regulations for Navigation in the NSRA 5e hereby &indly as& you to permit na$i*ation of the $essel ($essel4s name) in the Area of the Northern Sea Route 1n%losure (files in pdf format)6 1) !essel and $oya*e details as per Anne' 1 to the Re*ulations for Na$i*ation in the NSRA ") 0opy of !essel4s 0lassifi%ation 0ertifi%ate7 () 0opy of #onna*e 0ertifi%ate7 8) 0opies of do%uments on insuran%e and finan%ial se%urity 3ith re*ard to the 0i$il Ability for pollution dama*e %aused by the ship or any other dama*e %aused by the ship, issued by ,nternational #reaties in a%%ordan%e 3ith the Russian )ederation and the 9e*islation of the Russian )ederation (0i$il 9iability 0on$ention 0ertifi%ate (090), 0i$il 9iability for :un&er -il .ollution Dama*e 0on$ention 0ertifi%ate (09:0), a %ertifi%ate of insuran%e (hull insuran%e), in%ludin* insuran%e of additional ris&s at the Northern Sea Route) ;) 0opy of sin*le $oya*e %ertifi%ate issued by the or*ani+ation responsible for the %lassifi%ation and %ertifi%ation of ships that appro$ed this $oya*e (only for sin*le $oya*e $essel na$i*atin* outside the pres%ribed area and season ran*e of na$i*ation) <) 0opy of %ertifi%ate issued by the or*ani+ation responsible for the %lassifi%ation and %ertifi%ation of ships that appro$ed the to3in* pro=e%t, (only for to3in* $essel, in%ludin* to3in* of drillin* ri*s) >) 0opy of the Appli%ant4s do%ument of identity (for indi$iduals only) ?) 0opy of the do%ument %onfirmin* the authority of the person 3ho si*ned the appli%ation on his o3n behalf or on behalf of the Ship o3ner (for indi$iduals only)

Appli%ant4s .osition

Si*nature

)ull name