FCC Form 806 (for OMD 07312024)

FEDERAL COMMUNICATIONS COMMISSION Not Approved by OMB

3060-0228

Estimated Time Per Response: 10 Minutes

United States of America

CERTIFICATE OF COMPLIANCE WITH THE PROVISIONS OF THE RADIO PROVISIONS OF THE INTERNATIONAL CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974 (AS AMENDED) AND/OR SUBPART W

Particulars of ship

Name of Ship	Distinctive number or letters	Radio Call Sign	Port of Registry	Gross Tonnage

For passenger ships/vessels only, number of passengers for which certified_________________________________________________________

Minimum number of persons with required qualifications to operate the radio installations_____________________________________________

Sea areas in which ship is certified to operate (regulation IV/2)¹____________________________________________________________________

IMO number________________________________________________________________________________________________________________

Date of build:

Date of building contract______________________________________________________________________________________________

Date on which keel was laid or ship was at similar state of construction______________________________________________________

Date of delivery______________________________________________________________________________________________________

Date on which work for a conversion or an alteration or modification of a major character was commenced (where applicable)________

___________________________________________________________________________________________________________________

All applicable dates shall be completed.

Officer in Charge, Marine Safety Office,

United States Coast Guard

This is to inform you that the above-described ship was inspected at _________on _________________________________, 20______, by an FCC licensed technician and was found to comply with the radio provisions of Subpart W or the International Convention for the Safety of Life at Sea, as amended. It is desired that an appropriate certificate concerning the radio particulars, as provided in the Convention, be issued on behalf of this vessel. This certificate should include the following entries:

DETAILS OF RADIO FACILITIES Item

Actual Provision

Primary systems:……………………………………………………………………………… VHF radio installation:……………………………………………………………………. DSC encoder:..………………………………………………………………………… …. DSC watch receiver:………………………………………………………………… …… Radiotelephony:..…………………………………………………………………………. MF radio installation:……………………………………………………………………… DSC encoder:……………………………………………………………………………… DSC watch receiver:……………………………………………………………………… Radiotelephony:…………………………………………………………………………… MF/HF radio installation:…………………………………………………………………. DSC encoder:……………………………………………………………………………… DSC watch receiver:……………………………………………………………………… Radiotelephony:…………………………………………………………………………… Direct printing radiotelegraphy (required by Subpart W)……………………………… 1.4 Recognized mobile satellite service ship earth station:……………………………… Secondary means of initiating the transmission of ship-to-shore distress alerts:……………………………………………………………………………………………. Facilities for reception of maritime safety information (MSI) and search and rescue related information………………………………………………………………………………… EPIRB:……………………………………………………………………… ………………. 5. Two-way VHF radiotelephone apparatus:……………………………………………… Portable two-way VHF radiotelephone apparatus:……………………………………. 5.2 Two-way VHF radiotelephone apparatus fitted in survival craft…………………….. Search and rescue locating devices:……………………………………………………….. 6.1 Radar search and rescue transponders (radar SART) stowed for rapid placement in survival craft………………………………………………………………………………….. 6.2 Radar search and rescue transponders (radar SART) stowed in survival craft …………. 6.3 AIS search and rescue transmitters (AIS-SART) stowed for rapid placement in survival craft……………………………………………………………………………………………… 6.4 AIS search and rescue transmitters (AIS-SART) stowed in survival craft……………………………………………………………………………………………. Methods used to ensure availability of radio facilities (Reg. IV/15.6 and 15.7) Duplication of equipment:…………………………………………………………………… Shore-based maintenance:………………………………………………………………….. At-sea maintenance capability:……………………………………………………………

Was

THIS IS TO CERTIFY that this Record is correct in all respects.
Issued at (Place of issue of the Record):
Inspector Signature:
Date of Issue: (Seal or stamp of the issuing authority, as appropriate)

OMB Control Number 3060-0228

Notice to Individuals Required by the Privacy Act of 1974 and the Paperwork Reduction Act of 1995

The solicitation of information requested in this form is authorized by the Communications Act of 1934, as amended. The

Commission will use FCC-licensed technicians to conduct ship inspections and determine if the radio installation is in compliance with the requirements of the Communications Act of 1934, as amended. All information provided in this form, as well as the form itself, will be available for public inspection.

Public reporting burden for this collection of information is estimated to average 10 minutes per response. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, Office of Managing Director, AMD-PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060-0228). We will also accept your PRA comments via the internet if you e-mail PRA@fcc.gov.

Please DO NOT SEND COMPLETED FORMS TO THE POSTAL OR E-MAIL ADDRESS. You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0228.

THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31,1974, 5 U.S.C.

§ 552a(e)(3); AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, MAY 22,1995, 44 U.S.C. § 3507.

1 Per SOLAS, for a ship certified to operate in sea area A3, indicate the recognized mobile satellite service in brackets.

FCC Form 806 - Page 1

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