ANNEX 5

Name of ship

Distinctive number or letters

Flag State

[insert name of the ship]

[insert IMO number]

[insert name of the Flag State]

is in scheduled traffic with frequent and regular port calls at the following port(s) located in [insert name of the Member State] according to a schedule or predetermined route:

[]

and calls at these ports at least once a fortnight:

[]

and has made an arrangement to ensure the payment of the fees and the delivery of waste to the port or a third party at the port of:

[]

and is thus exempted, in accordance with [insert relevant provision in national legislation of the country], [from the requirements on:

mandatory delivery of waste from ships,

the advance waste notification, and

the payment of the mandatory fee, at the following port(s):]

This certificate is valid until [insert date], unless the grounds for issuing the certificate are changed before that date.

Place and date

Name

Title