Medallion Reederei GmbH

FORM.215 MATERIAL LANDING RECEIPT

Vessel: Receipt No.

Date Landed: (mm/dd/yyyy)

Port:

Item Description and Landing Reasons:

Instructions to Vendor:
Vendor to notify Technical Department via E-mail or fax immediately upon receipt of materials.
An estimate for repair should be sent to MEDALLION and a purchase order number received
prior to repair.

Address: Technical Department (MEDALLION REEDEREI)

Contact: MEDALLION - Email: technical@medallionmarine.com /
purchase@medallionmarine.com ,
Tel :+49 441 7705080, Fax: +49 441 77050822

Vendor must prepare service report (which must include name / quantity of parts
scrapped after repair) and attach a copy to this Landing Receipt. These documents to be
sent along with item/s being returned to the vessel, with copy to MEDALLION.

INSTRUCTIONS TO RECEIVER:
Ship materials per instructions below (Ship via: Next day Air, Ground, Sea):
Ship to: (Company Name)

(Address)

(City, State, Zip, Country)

(Telephone)

Additional instructions or information:

Receiver acknowledges the receipt and responsibility for the above listed materials.

Chief Officer or Receiver Receiver’s Name (printed)

Chief Engineer Receiver’s Company:      
VESSEL INSTRUCTIONS: This form must be used whenever any item is landed from the vessel.
Distribution: One copy goes with item landed. Second copy to be forwarded via mail to Technical Department.
Third copy remains onboard and filed in File# CE4
Rev Date: Apr 2011 Prep: DPA Appr: MD Ver: 1 Rev: 0 Page 1 of 2
Medallion Reederei GmbH
FORM.215 MATERIAL LANDING RECEIPT

VESSEL INSTRUCTIONS: This form must be used whenever any item is landed from the vessel.
Distribution: One copy goes with item landed. Second copy to be forwarded via mail to Technical Department.
Third copy remains onboard and filed in File# CE4
Rev Date: Apr 2011 Prep: DPA Appr: MD Ver: 1 Rev: 0 Page 2 of 2