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