Application for Inspection of Seafarers’ Working and Living Conditions
To NIPPON KAIJI KYOKAI (
branch / office )
Application No.
1. APPLICANT
Application Date
Name
Person in charge
(Stamp or signature)
Address
Name of Department
Tel
Fax
E-mail
Mobile No.
We acknowledge the provisions of “RULES FOR THE INSPECTION AND REGISTRATION OF MARITIME LABOUR SYSTEMS” and “CONDITIONS OF
SERVICE FOR CLASSIFICATION OF SHIPS AND REGISTRATION OF INSTALLATIONS” of NIPPON KAIJI KYOKAI (ClassNK) and request you to
carry out inspection(s) and to issue certificate(s) for the Maritime Labour System as mentioned below:
We ensure the payment of all inspection fees and expenses incurred in the below-mentioned inspection(s) and/or issue of relevant certificate(s).
2. KIND OF SHIPBOARD INSPECTION
Interim
Initial
Intermediate
Renewal
Additional
Remarks
Change of:
Shipowner
Flag
Recognized Organization
Others (
Date of Inspection
Port of Inspection
ETA/ETB
ETD
)
3. PARTICULARS OF SHIP
Name of Ship
Class & Class No.
IMO No.
Flag
Port of Registry
Gross Tonnage
*Type of Ship (in SMC/ISSC)
Date on which keel was laid
**Date of (expected) Registry
Crew Nationality
* In case the ship was constructed in compliance with the IMO Code of Safety for Special Purpose Ships (SPS Code), “Special Purpose Ship” is to be
described.
** The date when the ship was (will be) registered with the current flag is to be described referring to Certificate of Registry or Continuous Synopsis Record
(CSR).
4. INFORMATION TO MLC INSPECTOR
The DMLC Part II of the vessel:
is under reviewing
was reviewed (Letter of Review No. if reviewed by NK:
)
Name of authority / RO:
(For Initial inspection) The ship has been operated based on the measures set out in reviewed DMLC Part II since:
The master is familiar with the responsibility to implement and requirements of MLC, 2006:
The language to be used at the inspection:
English
Person appointed by the shipowner to accompany the inspector:
)
From ashore
Master
5. AGENT
Name
Person in charge
Address
Mobile No
Tel
MLC-APPLI-S (2015.6)
Yes
Other (
Fax
E-mail
1/2
Other (
)
6. DOCUMENTS(S) TO BE ATTACHED
- For Inspection for issuing interim MLC, Initial Inspection, or the vessel currently MLC certified by RO other than ClassNK: All
the documents mentioned below.
- For Intermediate/Renewal/Additional Inspection: A document(s) mentioned below when it’s issued/altered/rewritten after the latest
inspection.
(Provisional) Certificate of Registry and Continuous Synopsis Record (CSR)
DMLC Part I by the flag and DMLC Part II by the MLC Shipowner (Draft one(s) is acceptable for Inspection for issuing interim
MLC)
A document issued by RO or flag administration certifying completion of review of the DMLC Part II (or a document certifying
submission of the application for review of DMLC Part II, if the review has not been completed before Inspection for issuing interim
MLC)
A document such as certificate, statement, inspection report or survey report and etc., certifying compliance with the provisions of
crew accommodation facilities required to the vessel or Standard A3.1 of MLC, 2006.
Ship Inspection Certificate (For Japanese flag vessel only)
7. *MLC SHIPOWNER INFORMATION (For Japanese flag ship only)
Name of MLC Shipowner
Address of MLC Shipowner
* In case the MLC Shipowner differs from the applicant, please describe the name and address of MLC Shipowner referring to Ship Inspection Certificate or
Continuous Synopsis Record. The ship lessee (Bareboat Charterer) when the ship is being leased or the ship’s husband when the ship is commonly owned
is also included the definition of MLC Shipowner for Japanese flagged vessel.
8. BILLING CONTACT
(Note)Please complete the following in cases where the billing contact differs from the above applicant.
Name
Person in charge
Address
Name of Department
Tel
Fax
E-mail
9. MESSAGE AREA
MLC Shipowner means the owner of the ship or another organization or person, such as the manager, agent or bareboat charterer, who has
assumed the responsibility for the operation of the ship from the owner and who, on assuming such responsibility, has agreed to take over
the duties and responsibilities imposed on ship owners in accordance with this Convention, regardless of whether any other organization or
persons fulfill certain of the duties or responsibilities on behalf of the ship owner.
MLC-APPLI-S (2015.6)
2/2