M/S Date submitted

Dept. Date delivered

Port Port of delivery

	Very urgent (ship cannot		Urgent (required in		Planned (required for next dry dock or
	proceed without)		next port of call)		for normal operation)

No.	Name, specification	Unit	Qty remaining	Qty required	ISSA number

Submitted Confirmed Approved

_________________ _________________ __________________

Chief of Dept. Master Superintendent

Note: To be completed when necessary and filed in both office's file and ship's file.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-TD05-F03 Page: 1/2

REQUISITION FOR INVENTORY & MATERIALS NO.( )

QSMS PBO-TD05-F03 Rev. No.00

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