APPLICATION FOR CPC SURVEY

Reference No:

Date:

1. Shipper :
2. Address:
3. Tel No:
4. Consignee / Notify Party :

INSPECTION PLACE / SCHEDULE

(a) Inspection Time & Date :
(b) Name of Company :
(c) Place :

(d) Responsible Person in Charge :

(e) Tel No:
Please attach the following documents three (3) working days prior to inspection/stuffing.
1)
2)
3)

Material Safety Data Sheet ( MSDS) or Chemical Safety Data Sheet (CSDS)
Packing List
CPC Form to be fill out (as enclosed)

TERMS AND CONDITION OF CPC SURVEY

1)
2)
3)
4)

5)

Information, documents and contents of cargo packed which are produced for the purpose of this inspection is taken in good
faith and we cannot be held responsible for any costs and/ or consequences, caused directly or indirectly by your failure to
provide such correct information and/or documents as required by Law.
The certificate is issued based on visual inspection on the conditions at the time and place of survey.
The surveyor shall be under no liability whatsoever to the client for any loss, damage, delay or expense of information,
documents provided and visual inspection only.
The shipper (Cargo Owner) undertake to hold the surveyor fully harmless and indemnify them against any and /or all losses,
damage, expense resulting from the failure to comply with the above and/or requirements of CPC in accordance with UN
IMDG, SOLAS 74, Chapter VII, regulations 5 and MARPOL 73/78, Annex III, regulations 4 and LPK by Law amendment
1989.
That, subject to the above, to total liability of Survey Company, its officers and employees for any loss or damage caused by
or resulting from improper or negligent performance, purported performance or non performance of such work if proven,
shall not exceed a sum equal to five times the fee payable for the work.

Signature: ______________________

Designation: __________________

Name: ________________________

Date: ________________________

Company Stamp
_____________________