Br :................. Bar:..............

ZAHTJEV ZA TEHNIČKI PREGLED JAHTE REQUEST FOR TECHNICAL SURVEY OF YACHT

U skladu sa Zakonom o jahtama („Sl. list RCG“ br.46/07) i Pravilima za statutarnu sertifikaciju jahti,zahtijevamo da nam izvršite tehnički pregled jahte zbog upisa u Registar jahti Crne Gore. In accordance with the Law on Yachts and the Rules of statutory certification of yachts, we request that you perform technical survey of yacht for the registration in the Register of Montenegro.

Ime jahte Name of the yacht

Broj trupa Hull number

Tip/Model jahte Yacht type/model

Snaga motora Engine power

Godina gradnje Year of built

Registarski broj Register No.

Materijal - Material Dužina-Length Širina-Breadth Gaz-Draught Bruto tonaža- GT Istisnina-Displacement

Ime i adresa vlasnika Name and address of the Owner

Sanitarni tank Sewage tank Yes No

Tank ulja Oil tank Yes No

Kante za sakupljanje kom. otpada Garbage collecting boxes Yes No

Mjesto pregleda Place of survey

Na suvom U vodi In dry dock In water

Broj ležaja No. of berths

Područje plovidbe Area of navigation

Max. broj lica na jahti Max. number of persons on the yacht

VHF Radio VHF radio

Yes No

Jahta će biti spremna za početak pregleda (datum): Yacht will be ready for survey (date):

Vrsta pregleda: Type of survey:

Dolje potpisani izjavljuje da su svi navedeni podaci tačni,i da prihvata sve uslove koji proizlaze iz Zakona o jahtama i Pravila za statutarnu sertifikaciju jahti. (The undersigned declare that all given details are correct, and accept all conditions arising from the Law on Yachts and the rules for statutory certification of yachts.)

Kontakt osoba za pregled ....................................................... Telefon............................................... Contact person for survey Telephone

Potpis podnosioca zahtjeva ( Signature of Requester)

…………………………………… OB_36 Izdanje 1

CRNA GORA

REGISTAR JAHTI

MONTENEGRO YACHT REGISTER

UPRAVA POMORSKE SIGURNOSTI -- MARITIME SAFETY DEPARTMENT

Maršala Tita br. 7- PO Box 14, 85 000 BAR