[별지 제11호서식] <개정 2017. 6. 2.>

(제1쪽)

선박이력기록부

Continuous Synopsis Record(CSR) Document Number_____for

the Ship with IMO Number: IMO _________

	기재사항(Information)
1	적용일자 This document applies from (date):
2	기국 Flag State :
3	기국등록일 Date of registration with the State indicated in 2:
4	선박명 Name of ship:
5	선적항 Port of registration:
6	선박회사 명칭/주소 Name of current registered owner(s): Registered address(es):
7	선박회사 식별번호 Registered owner identification number:
8	나용선인 경우 나용선주 명칭/주소 If applicable, name of current registered bareboat charterer(s): Registered address(es):
9	안전관리회사 명칭/본사주소/주사업장소 Name of Company (International Safety Management): Registered address(es): Address(es) of its safety management activities:
10	안전관리회사 식별번호 Company identification number:
11	선급명 Name of all classification societies with which the ship is classed:
12	DOC발급기관명/발급기관과 다른 경우 심사기관명 Administration/Government/Recognized Organization which issued Document of Compliance: Body which carried out audit (if different):
13	SMC발급기관명/발급기관과 다른 경우 심사기관명 Administration/Government/Recognized Organization which issued Safety Management Certificate: Body which carried out audit (if different):
14	ISSC발급기관명/발급기관과 다른 경우 심사기관명 Administration/Government/Recognized Organization which issued International Ship Security Certificate: Body which carried out audit (if different):
15	말소등록일 Date on which the ship ceased to be registered with the State indicated in 2:
16	Remarks(비고) (insert relevant information as appropriate).

이 증서는 위의 모든 기록이 틀림없음을 증명합니다

THIS IS TO CERTIFY THAT this record is correct in all respects

발급기관/ Issued by the Administration of:

발급장소 및 발급일/ Place and date of issue:

인가자서명/ Signature of authorized person:

인가자명/ Name of authorized person:

본선 수령일 및 수령자 서명/

This document was received by the ship and attached to the ship’s CSR file on the  following date:                           Signature:

210㎜×297㎜[보존용지(2종) 70g/㎡]

선박이력기록부의 개정서식 (제2쪽) Amendments to the Continuous Synopsis Record(CSR) Document Number for the Ship with IMO Number: IMO ____________
	기재사항(Information)
1	적용일자 This document applies from (date):
2	기국 Flag State:
3	기국등록일 Date of registration with the State indicated in 2:
4	선박명 Name of ship:
5	선적항 Port of registration:
6	선박회사 명칭/주소 Name of current registered owner(s): Registered address(es):
7	선박회사 식별번호 Registered owner identification number:
8	나용선인 경우 나용선주 명칭/주소 If applicable, name of current registered bareboat charterer(s): Registered address(es):
9	안전관리회사 명칭/본사주소/주사업장소 Name of Company (International Safety Management): Registered address(es): Address(es) of its safety management activities:
10	안전관리회사 식별번호 Company identification number:
11	선급명 Name of all classification societies with which the ship is classed:
12	DOC발급기관명/발급기관과 다른 경우 심사기관명 Administration/Government/Recognized Organization which issued Document of Compliance: Body which carried out audit (if different):
13	SMC발급기관명/발급기관과 다른 경우 심사기관명 Administration/Government/Recognized Organization which issued Safety Management Certificate: Body which carried out audit (if different):
14	ISSC발급기관명/발급기관과 다른 경우 심사기관명 Administration/Government/Recognized Organization which issued International Ship Security Certificate: Body which carried out audit (if different):
15	말소등록일 Date on which the ship ceased to be registered with the State indicated in 2:
16	Remarks(비고) (insert relevant information as appropriate)
이 증서는 위의 모든 기록이 틀림없음을 증명합니다 THIS IS TO CERTIFY THAT this record is correct in all respects 발급자/Issued by the Company or Master: ----------_____________________ 발급일자/Date of issue: _____________________________________ 인가자 서명/Signature of authorized person: ____________________ 인가자명/Name of authorized person: _________________________

선박이력기록부 개정사항 색인목록 (제3쪽) Index of Amendments to Continuous Synopsis Record(CSR) Document Number ____ for the Ship with IMO Number: IMO ________ 선박이력기록부가 발급된 후에 다음의 기재사항이 회사나 선장에 의해 기재되었고 선박이력기록부에 첨부되었으며 기국 정부에 통보되어진 사항들이다. After this CSR document was issued, the following amendments to entries on the document have been made by the Company or the master, have been attached to the ship’s CSR file and have been notified to the Administration:
개정사항의 적용일자/Date of Application of Amendments	CSR 정보 2번～13번까지의 개정사항/Amendments to CSR Information(2-13)	개정사항 양식의 CSR에 첨부된 날짜/ Date Amendment Form attached to the ship’s CSR file:
NOTE: 위의 표에 추가하여 개정이력이 있는 경우 양식을 추가할 수 있으며, 아래와 같이 첫장을 1번으로 하고 이후 번호가 차례로 매겨져야 함 If more amendments are issued than allowed for in the above table, add copies of this table as Appendices to this page. Such Appendices should be numbered from 1 and upwards. When relevant, indicate as follows: 첨부 번호 이 이 쪽에 추가되었음 Appendix no: ____________ has been added to this page.

(제4쪽)

기재 시 참고사항

1. 이 서식 중 제1쪽의 기재사항은 관할 지방해양수산청장 외의 자가 수정ㆍ삭제하여서는 아니 되며, 선박이력기록부 기재내용은 한글과 영문으로 함께 작성하여야 한다.

2. 국제항해선박의 선장이나 국제항해선박소유자는 「국제항해선박 및 항만시설의 보안에 관한 법률 시행규칙」 제16조제4항에 따른 선박이력기록부 기재사항 중 제4호부터 제12호까지의 내용이 변경되었을 때에는 「국제항해선박 및 항만시설의 보안에 관한 법률」 제16조제2항에 따라 선박이력기록부를 재교부받을 때까지 이 서식 제2쪽의 기재사항(Information) 난에 그 변경사항을 적어 그 국제항해선박에 갖추어 두어야 한다.