APPLICATION FOR ISSUANCE OF EIAPP CERTIFICATE OF MARPOL 7378

Category of

Application

　New　　　　Reissue　　　Rewrite

Number of

required document

Orig./Copy 　1/　　

Engine Manufacture 　& Address

＊To be stated on EIAPP certificate.

Engine Manufacture

Address

Information of

Engine Tested

＊In case of Re-issue or Re-write, from a to f shall be written.

a. Category

　Engine Family　or　 Engine Group

　Parent or 　　Member

b. Name of Engine Family / Group

c. Engine Type

d. Output

kW

e. Speed

rpm

f. Serial Number

g. Test Cycle

h. Date of build

1. Date of Test

Applied Regulation

　Tier I　　　　Tier II　　　　　Tier III　　　　　　Approved Method

（Reg. 13.3）　　（Reg. 13.4、　　　（Reg. 13.5.1.1）　　（Approval or Installation）＊

　　　　　　　　　　13.2.2又は13.5.2）＊　　　　　　　　　 ＊：Delete as appropriate

Test Place

＊In case of New

Company’s Name & Address

Contact Personnel (Tel, Fax and E-mail)

Information of

Parent Engine and Installed Ship

＊In case of New and Member Engine

Certificate Number

Date of Issue

Technical File No. and Approval No.

Date of approval

Class (IMO) No. or

Ship Builder / No.

Flag

Information of

Re-issue or Re-write

＊In case of Re-issue or re-write

Certificate Number

Date of Issue

Reason

Information of Modification

• In case of　Modification

Ship’s Name

Class Number

Date （Plan）

Date of start of work

Contents of Modification

Attached documents

Manufacturing spec. of Engine

Documents for selection of parent engine

Drawings for Engine

Technical File

Documents for material of engine　parts

Plan for NOx measurement

Documents for definition of Engine Family/Group

EIAPP certificate

Other：

Shipping/Billing address

＊In cases where the address is different from the applicant