Vessel : __________________________ Place/Port : ______________________

Voy. No. : ________________________ Date : ___________________________

This form should be completed and forwarded to the DPA at the first opportunity.

Description of the fact:

The Related Documents attached list:

Master : ___________________________________

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∗02-F02 Page: 1/1

SEA PROTEST

QSMS PBO-G∗02-F02 Rev. No.00

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