Application for Shipboard Audit of SMS A copy of effective DOC

							                                                                                             Date:

To   NIPPON KAIJI KYOKAI

                                    Application for Shipboard Audit of SMS
We acknowledge the provisions of “RULES FOR THE AUDIT AND REGISTRATION OF SAFETY MANAGEMENT
SYSTEMS” and “CONDITIONS OF SERVICE FOR CLASSIFICATION OF SHIPS AND REGISTRATION OF
INSTALLATIONS” of NIPPON KAIJI KYOKAI(ClassNK) and request you to carry out audit / to issue certificate for
the Shipboard Safety Management System as mentioned below:


Type of Audit                    Initial       Intermediate         Renewal            Issuing Interim SMC (the Rules 2.3.3 -1)

                                 Additional ( Note                  )     for DNC ( Relevant Record No                         )

Ship                     Name of ship:

                         Classification & Class No.:

                         IMO Number:                                     Cert. No. of SMC:

                         Flag:                                           Port of Registry:

                         Call sign:                                      Official No.:

                         Type of Ship:                                   Gross Tonnage:


Company’s details        Cert. No. of DOC:

                         Date of last Annual Audit:

                         Name of Company:

                         Person in charge:

                         Address:

                         Telephone No.:                                       Fax No.:


Audit Schedule           Date:                                                Place:

                         Name of Agent:

                           ( Telephone No.:                                     Fax No.:                                   )


All fees and expenses incurred in the above mentioned audit and issue of certificate are paid by;

Name of Company:

Address

Telephone No.:                                           Fax No.:

Applicant’s signature:

                             (                                                               )

Attached: A copy of effective DOC issued under the authority of the Administration.
Note: In the case of Non-NK Class ship, a copy of (Provisional) Certificate of Registry shall be attached.


APPLI-S (2005.12.1)