Report No: _______________________ Date: ________________________

Ship's Name: _____________________ Place: ________________________

Report to:

Subject of Complaint:

Cause of Complaint: Master:___________________________

Note: To be completed by case and filed in both office's file and ship's office.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-G∗07-F02 Page: 1/1

MASTER'S COMPLAINT REPORTS

QSMS PBO-G∗07-F02 Rev. No.00

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