PANAMA MARITIME AUTHORITY

Application for

CONTINUOUS SYNOPSIS RECORD (CSR)

 

 

Document Number (leave blank): ________  for the ship with IMO Number:__________

 

All information listed should be filled in.  Indicate N/A if “not applicable”.

 

 

INFORMATION

1

This document applies from (date):

 

2

Flag State:

 

3

Date of registration:

 

4

Name of ship:

 

5

Port of registration:

 

6

Name of current registered owner(s): Registered address(es):

 

 

 

 

7

Name of current registered bareboat charterer(s):

Registered address(es):

 

8

Name of Company (ISM):

Registered address(es):

Address(es) of its safety management activities:

 

9

Name of all classification societies with which the ship is classed:

 

10

Adm./Government/Recognized Org. which issued DOC:

Body which carried out audit (if different):

 

11

Adm./Government/Recognized Org.

which issued SMC:

Body which carried out audit (if different):

 

12

Adm./Government/Recognized Org. which issued ISSC:

Body which carried out verification (if different):

 

13

Date on which the ship ceased to be registered with the State indicated in 2:

 

 

THIS IS TO CERTIFY THAT this record is correct in all respects

 

Issued by the Administration of: ………………………………………………….

Place and date of issue: …………………………………………………………..

Signature of authorized officer: …………………………………………………..

Name of authorized officer: ……………………………………………………….