No: R - 07

POSEIDON SA Page:
Date:
1 of 1
01/12/15
Rev.: 0

VESSEL:___________________ DATE:__________________

COMPLAINT

NAME & SIGNATURE:_____________________ SIGNATURE: _____________________

(PERSON INFORMED) (ORIGINATOR)

NAME & SIGNATURE:_____________________ SIGNATURE: _____________________

(PERSON INFORMED) (REPRESENTATIVE IF ANY)

NAME & SIGNATURE:_____________________

(PERSON INFORMED)

INVESTIGATION ONBOARD

DATE OF COMPLETION: ________________ SIGNATURE: _____________________

(INVESTIGATOR)

INVESTIGATION ASHORE (IF REQUIRED)

DATE OF COMPLETION: ________________ SIGNATURE: _____________________

(DPA)

VERIFICATION AND CLOSE OUT

CLOSE OUT DATE: SIGNATURE:

(ORIGINATORS ACCEPTANCE)

MASTER (If Involved): ____________________

Note: For each complaint file, original to be kept on board and copy handed to crew member filing the complaint.

Contacts of Seafarers competent authority

Name / Dept : Department of Maritime Labour Affairs
Tel / Fax : (001) (507) 501-5059
Email : mlcsegumar@amp.gob.pa