Ascent Navals Register

Samoa Maritime Authority & Administration

Ministry of Works, Transport & Infrastructure, Government of Samoa
Technical & Administrative Office: Thailand -Ascent Navals, 61/2-3, Sailourd Road, Paknam Samutprakan, Phone: +66-027017277
Technical Extension Office: India -Ascent Navals, SCO 177, 2nd floor, Sector 37-C, Chandigarh-160036, Phone: +91-1725051429
Website: www.ascentregister.com, E. mail: manager@ascent-mwti.com

FORM- 029/SMAA
Application form for MLC Inspection
“To be filled by shipowner”

Details of ship:

Name of ship IMO No Port of Registry Type of ship Official No

Details of Inspection:
Type of inspection requested Reason (specify in case of Proposed Place of Inspection Proposed Date of Inspection
additional inspection

Details of Shipowner:
DOC Company:
Shipowner contact person Email ID
Name of shipowner Telephone No:
Shipowner identification number Fax No:
Billing Address
Outstanding deficiencies (if applicable from previous inspection) Yes/No
FSI/FSC Deficiency if any from previous inspection Yes/No
DMLC part II attached for review:
a) To administration Yes/No
b) To ANT Yes/No

MLC/04/17/ Rev: 01
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 Ascent Navals Register
Samoa Maritime Authority & Administration
Ministry of Works, Transport & Infrastructure, Government of Samoa
Technical & Administrative Office: Thailand -Ascent Navals, 61/2-3, Sailourd Road, Paknam Samutprakan, Phone: +66-027017277
Technical Extension Office: India -Ascent Navals, SCO 177, 2nd floor, Sector 37-C, Chandigarh-160036, Phone: +91-1725051429
Website: www.ascentregister.com, E. mail: manager@ascent-mwti.com

Details of Existing MLC Certificates: Yes/No

MLC Certificate Number

Certificate Date of Issued by Issued At Reviewed Reviewed Valid Till

issue By Date
Maritime Labour
Certificate
DMLC Part I

DMLC Part II

I/We, whose name(s) is/are hereunto subscribed, hereby certify that:

1. I/We am/are duly authorized to make this application;

2. the information given in this application and the documents submitted herewith are true
and correct.

Date: Signature:________________________________
(Signature(s) of declarant(s))
Name of declarant(s):

MLC/04/17/ Rev: 01
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