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In accordance with the provision of paragraph 3.7.3 of IMO Port State
Control Procedures (resolution A.1052(27))
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(Copy to maritime Authority of next port of call, flag Administration, or
other certifying authority as appropriate)
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1
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From (Country/region)
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2
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Port
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3
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To (Country/region)
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4
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Port
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5
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Name of ship
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Date
departed ............................................
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7
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Estimated place and time of arrival
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8
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IMO number
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9
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Flag of
ship and POR ................................
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Type of ship
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11
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Call
sign .....................................................
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12
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Gross tonnage
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13
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Year of
build ..............................................
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14
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Issuing
authority of relevant certificate(s)
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15
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Nature of deficiencies to be rectified
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16
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Suggested action (including action at next port of call)
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……………………………………………….
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17
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.Action taken
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Reporting Authority
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Office
.......................................................
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Name
.......................................................
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Telefax
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(duly authorized PSCO of reporting authority)
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Signature
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Date
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