Declaration Form Dgs-01 printable pdf download

Declaration Form Dgs-01

DECLARATION

FORM NO. DGS/ISM - 01

(To be completed by authorised representatives of the owner / bareboat charterer and the company on first notification

and when reporting any changes thereafter)

VESSEL

Name of Vessel:

Type of Vessel:

Official No. / Call Sign:

IMO Number:

OWNER / BAREBOAT CHARTERER

Registered Name:

(Enclose certificate of Incorporation)

Registered Address:

Tel. No.:

Fax No.:

E-mail:

DECLARATION OF PARTICULARS OF THE COMPANY (ISM Code Ref.: 1.1.2)

Registered Name:

(Enclose certificate of Incorporation)

COMPANY ID NO.

Registered Address:

Operation Office Address:

Tel. No.:

Fax No.:

Telex No.:

E-mail:

I, the undersigned, hereby declare and state for and on behalf of the company that the above

information is true and correct and I am duly authorised by the company to provide the aforesaid

information.

Name:

Place & Date:

Signature:

Stamp:

I, the undersigned, hereby declare and state for and on behalf of the owner / bareboat charterer that

the above information is true and correct and I am duly authorised by the owner / bareboat charterer

to provide the aforesaid information.

Name:

Place & Date:

Signature:

Stamp:

Certified by

Name & Stamp of the Registrar of Ship

Declaration Form Dgs-01