(Requester’s name ) / (dd/mm/yyyy)
Main Particulars of Ship & Shipowner
Name of ship
Distinctive number or letters
Port of registry
Date of registry (dd/mm/yyyy)
Gross tonnage
IMO number
Type of ship
Maximum of crew members according the accommodation arrangements
IMO Unique Registered Owner Identification Number (*)
Name and address of the Shipowner (*)
IMO Unique Company Identification Number (*)
Name and address of the Company (*)
(*) If the Registered Owner and the Company is the same, please kindly indicate the name and address information in only one box
Type of Certification
X-- / DMLC-Part II-Review & Endorsement (1st Review & Endorsement OR Amendments of previous DMLC-Part II)
X-- / MLC/DOC/IC -Valid for six (6) months (for non-ratifying countries) following Voluntary Inspection
X-- / MLC/DOC/FT-Valid for one (1) year (for non-ratifying countries) following Voluntary Inspection
X-- / MLC/IC- Valid for six (6) months following verification of Standard A5.1.3.7
X-- / MLC/ST-Valid for five (5) months following Initial/Renewal/Additional Inspection
X-- / MLC/FT-Valid for five (5) years following Initial/Renewal/Additional Inspection
X-- / Other Type of Certification (Specify):
Other Certification ( Specify):
Type of Inspection
X-- / Interim Inspection (Standard A5.1.3.7)
X-- / Initial Inspection
X-- / Intermediate Inspection
X-- / Renewal Inspection
X-- / Additional Inspection
X-- / Other Inspection (Specify):
Certification Scenarios
X-- / Voluntary Certification / X-- / Change of Shipowner Name
X-- / Change of Recognized Organization (RO) / X-- / Change of Shipowner Address
X-- / Change of Shipowner / X-- / DMLC-Part II (1st Review & Endorsement OR Amendments of previous DMLC-Part II)
X-- / Change of Flag / X-- / Re-activation of Certification
X-- / Change of Ship’s Name / X-- / Other scenario (Specify):
Note: Copy of existing MLC to be submitted to the ICS-Head Office including page with intermediate/additional endorsements (if apply)
QP 3.3-1/Form 03 1/1