Date : _________________________ Reg. No. ____________________

Relating report of QSMS deficiency: Main facts:
The corrective / prevention action shall be taken: Manager of relevant dept. (state)________________
For Divisional Director approval Shipping (Technical) Director________________	For DPA/MR approval if amendments to QSMS documentation required DPA/MR ___________________

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

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-G∗13-F02 Page: 1/1

CORRECTIVE / PREVENTION ACTION NOTICE

QSMS PBO-G∗13-F02 Rev. No.00

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