Client Questionnaire- Maritime Labour Convention
(Information for Preparation of Proposal)
For a quick response, this questionnaire may be faxed or e-mailed directly to:
Fax: 1-281-877-6001
(Americas)
Email: msc-amer@eagle.org
Fax: 30-210-9403610
(Europe)
Email: msc-eur@eagle.org
Fax: 65-6275-0258
(Pacific)
Email: msc-pac@eagle.org
Fax: 86-21-6322-9649
(Greater China)
Email: msc-china@eagle.org
1. General Information
PHYSICAL ADDRESS
.
Company Name
Company IMO Number 1
Address
City
State or Country
Contact Person
Title
Phone
Fax
Postal Code
Email
☐ SAME AS PHYSICAL
BILLING/INVOICING ADDRESS
Address
City
State or Country
Contact Person
Title
Phone
Fax
Postal Code
Email
☐ SAME AS PHYSICAL
CORRESPONDENCE ADDRESS
Address
City
State or Country
Contact Person
Title
Phone
Fax
Postal Code
Email
1
Lloyd’s Register Fairplay issues unique Company Identification Numbers. For more information on obtaining this identification number visit
http://imonumbers.lrfairplay.com
MSC Administration
SWZ-122-01-P01
Form C – Rev. 1
Page 1 of 3
Client Questionnaire- Maritime Labour Convention
(Information for Preparation of Proposal)
2. Fleet Vessel Information
The information provided will assist ABS in estimating the fees associated with DMLC Part II reviews and
shipboard inspections, as well as identifying any special requirements that may apply. Please complete table below
or attach separate sheet(s).
Vessel Name
2
3
Vessel Type
Vessel
IMO No.
Registry2
Reg.
Date3
Class No.
Flag of Registry
Date of Registry from Continuous Synopsis Record (CSR) or Provisional Certificate of Registry
MSC Administration
SWZ-122-01-P01
Form C – Rev. 1
Page 2 of 3
Number
of
Seafarers
Client Questionnaire- Maritime Labour Convention
(Information for Preparation of Proposal)
1
3. Planning Information:
Projected Date:
DMLC Part II Review:
Pre-assessment (optional):
Certification Assessment:
4. Additional Information or comments (if any):
ABS Use Only
MSC Administration
SWZ-122-01-P01
Division
Received By:
Reviewed By:
Form C – Rev. 1
Page 3 of 3