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In accordance with the provision of paragraph
3.7.3 of Procedures for port State control (resolution
A.1155(32))
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(by telefax/email and/or mail)
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To: (Name)
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(Position)
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(Authority)
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Telephone
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Telefax/email
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2
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From: (Name)
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(Position)
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(Authority)
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Telephone
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Telefax/email
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Name of ship
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4
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Call sign
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IMO Number
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Port of inspection
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7
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Date of inspection
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8
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Action taken
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a) Deficiencies
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b) Action taken
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9
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Next port
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(Date)
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10
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Supporting documentation
No Yes
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(See attached)
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Signature
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