| 1 From (country/region)
..............................
|
2 Port
..........................................................
|
| 3 To (country/region)
..................................
|
4 Port
..........................................................
|
| 5 Name of ship
...........................................
|
6 Date departed
...........................................
|
| 7 Estimated
place and time of arrival
........................................................................................
|
| 8 IMO number
.............................................
|
9 Flag of ship and POR
...............................
|
| 10 Type of ship
.............................................
|
11 Call sign
...................................................
|
| 12 Gross tonnage
.........................................
|
13 Year of build
.............................................
|
| 14 Issuing
authority of relevant certificate(s)
...............................................................................
|
| 15 Nature of
deficiencies to be rectified
|
16 Suggested
action
|
|
|
(including action at next
port of call)
|
| ………………………………………………..
|
………………………………………………..
|
| ………………………………………………..
|
………………………………………………..
|
| ………………………………………………..
|
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|
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|
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|
| ………………………………………………..
|
………………………………………………..
|
| ………………………………………………..
|
………………………………………………..
|
| ………………………………………………..
|
………………………………………………..
|
| 17 Action
taken
|
| …………………………………………………….………………………………………………
|
| …………………………………………………….………………………………………………
|
| …………………………………………………….………………………………………………
|
| …………………………………………………….………………………………………………
|
| …………………………………………………….………………………………………………
|
| …………………………………………………….………………………………………………
|
| …………………………………………………….………………………………………………
|
| Reporting Authority
.....................................
|
Office
......................................................
|
| Name
......................................................
|
Telefax/email
|
| ....................................................
|
|
| (duly authorized PSCO of
reporting authority)
|
|
| Signature
.....................................................
|
Date
........................................................
|