REPORT OF DEFICIENCIES
NOT FULLY RECTIFIED OR ONLY PROVISIONALLY RECTIFIED
In accordance with the provision of paragraph 3.7.3 of
Procedures for Port State Control (resolution A. 1185(33))
(Copy to maritime authority of next port of call, flag Administration,
or other certifying authority as appropriate)
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)
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..
17 Action taken
…………………………………………………….………………………………………………………………………………………………………….
…………………………………………………….………………………………………………………………………………………………………….
…………………………………………………….………………………………………………………………………………………………………….
…………………………………………………….………………………………………………………………………………………………………….
…………………………………………………….………………………………………………………………………………………………………….
…………………………………………………….………………………………………………………………………………………………………….
…………………………………………………….………………………………………………………………………………………………………….
Reporting authority ………………………………. Office ………………………………………………
Name ………………………………………………
Telefax/email…………………………………………….
(duly authorized PSCO of reporting authority)
Signature Date