A

DELTA MARITIME & INDUSTRIAL SKILL TRAINING

AL
-,
INSTITUTE PRIVATE LIMITEI)
CIN : U74999MH201 4PTC260088

Ref No: DMtSTt/23-24/ 34 Date: 08th September 2023

To,
Directorate General of Shipping,
9th Floor Beta Building, l-Think,
Techno Campus, Kanjurmarg,
(East), Mumbai - 4OO O42.

Sub: Request for issue of ISM Audit (Delta Maritime and lndustrial Skill Training tnstitute Private Limited-
s880620)

Respected Sir,

Kindly find ISM Form -1, ISM FORM-2, ISM FORM-11& ISM FORM-12 duly stamp signed by authorized
person are forwarded as enclosure to this letter for authorized IRS to carry out ISM Audit of the vessel
M P WORKBOAT-I(OFF NO.4s69)

2 . lt is requested that receipt of the letter may please be acknowledge.

Thanking you

Enclosure l. ISM FORM - 1

ll. tsM FoRM-2
ilt.tsM FoRM-11
IV.ISM FORM-12

Capt.

Training !nstitute Private

ADDRESS: - 1O4,FLOOR.11 PLOT-sg, ABHAY STEEL HOUSE, BARODA STREET, TATA POWER CARNAC BUNDER, CHINCHBUNDER,
MUMBAT-400009.
Emalls: marineservices@deltamaritime.in . Phones : 022-49737046
 .D, EC-LARATJENTSEM
NCI.DGSIISM.O,!
(Tobecompletedbyauthorizedrepresentatives oftheowner/bareboatchartererandthecompanyoniirsinotif ication
andwhenreportinganychangesthereafter)

VESSEL
Name ofVessel: f-.1 p v,.l oR K 8o Ar .l Type ofVessel 5/ f-( I.A L Po R lose 5 i)>P

OfficialNo. / CallSign: vr Ar /q569 rMoNumbec 3,t-++438

of Fs l'\o R€- PRt-'t ATf- Lt N TTf- a

RegisteredName: R O ct
1En-close copy of Certificateof lncorporation and Certificate
of Registry of the vessel)
:of(s-Le r{o.o5t3Ro f LooR Tel.No.:
Rr--pA1 N"nEJ TLRRAce tlll ,0v. Aartff^
4F-Sanrr^ R",AO twoALC ,1.l ,Hi3AL -{oool! aJci ,{{shovep vivo-le oi l. cor^

J. PANY(lSMCode Ref.:1
ng Fr{o !/.,ouJTaLR L s r<5 LL "t-R O LN'EN g
(Enclosecertificateof lncorporation) rru-sr LrurL PAT-vATe LLfi LTe O

COMPANYIDNO. 5 B{ O AUo
0 f- r't u'11I
Operation OtficeAddress: of F tCL N o. I o l,
RL|o,-rf, rJEooua frp.t. N€op ov6a tLooe ,puT s9 taar4A.r JT6cL
HL oLcAL coLLr? gL,fr6l+o L€ goio lrtn
IIOUJE,BARODA ITRTTT I U€NR 'TA1A
r^ r19o R,arrAr-ip Sl o, o -[o* R r{ourL , cARNAL Bvr,to€.Rtcl_tIwr tt
liaALgt{AR I Ptnr . 4ot i"i,
lP^owf.
^ o^'ur^.ro,lA-vN o € R , uu n$a r / H R q A R RJtdT a A
11taq
lPr-x - 4oo ooi,
rer.No.: 1+"13o344o Tel.No.: +31 LLqg +S7o/, I
FaxNo.: FaxNo.:
TelexNo.: TelexNo.:
E+nail: m ,.vlA e j ev v icesA.J e I lama-ri li qe. t E-mail: nt *t ia e Sevv i ce s G-J e I tono- il int, n
l,theundersigned,herebydeclareandstaieforandonbehalfofthecompanythat theabove
informationistrueandcorrectandlamdulyauthorizedbythecormpanytoprovide theaforesaid information.

cApf. Gt+A6wRru JtNgH Place Fvn0a ;:/ /o s lzoz

I i
l,theundersigned, herebYdeclare and stateforand on
t r. .t..^, .4h
theabov einform ation sirueand
i L;UI I Cutal lU -*
ldl lluulycluU lul tzEtru
^-:*^dL

ici etheaf oresai d i nf o rm ati on

:rtR. otie.pnw f" o0stiJ Place &Date: rutnv.flgraT 4nlotlzs
-
Sionature: Stamp:

\*uo,-
Certifiedby V{2
Nam e&Stam pofth eR eg i strarof S hi p

MS Notice 9 of 2014 Page 1.6

 Annexto FormNo.DGSllSM -0'i
(robecompretedbyauthorizedrer::"ffi;}|ffi:ff:fA;X,1::3;!;::i""otnecompanvonfirstnotification

$,q
Forandonbehalfofthe OwEer/ Baraboat€hari'erer: Forando nbehalfofthe Com PanY:

l,the undersigned,herebydeclai-eand stateas below: l,the undersignecl,herebycieclareand stateas beiow:

1 ; Th e companyhasacceptedthe agreementwththe
@rtererh asag reern entwith -
the companyforthe operationsofthe .vesselandto
owner/bareboatchartererand undertaketocarry
discharge' of all duties, responsibilities and outallaspectsoft heoperationoft hevesseland
obligati5nsofthe owner/bareboatcharterer,which dischargeallduties, responsibilitiesandobligations
fallwithinth escopeofChapterlXoftheSO LAS, ofihe owner/bareboatcharterer,whichfallwithin the
l gT4asamendedand Merchant Shipping scopeofChapterlXofthe SOLAS,l 974as
(Management for the Safe Operation of Shipsl amendedand Merchani Shipping (Management for the
Rules,- 2000, as amended fromthedateofthe Safe Operation of Ships) Rules, 2000, as amended,
presentdeclaration. fromihe dateoft he presentdecl aration.

@Chartererhas read and @vedfromtheowner/

' bareboat charterer sufficient instructions,guidance,
understoodthe Merchant Shipping (Management for
ihe Safe Operation of Ships) Rules, 2000, as m eansandresourcestotheentiresatis{actionof
amended,andtherequirementof the D'G' the companyandarangementshavebeenmade
Shipping on the develoPment, whichenableandwillenablethe companytocarry
implem6ntationandceriifl cationofSMsissuedby the outandfulfillthe duties,responsibilitiesand
D.G.ShipPing. obligationswhichare herebyacceptedand
unciertaken.

e; tneowner/ bareboat charterer accepts, agrees
' andundertakestoberesponsibleforthecompany
(namedoverleaf).
StTh ecom panyaccepis,ag reesandunde rtakesto.
' bebouni,aifarastheoperationofthevesseland
foranymaiter rel ated thereto, bytheappli cable
rulesand regulationsofthe D.G.Shipping.

@istrueandlamdulY @jbrstood the Merchan'

' Shipping (Management for the Safe
for and on Operation o'
to make this declaration
authorised -
behalfofthe orivner/ bareboatcharterer. Shi!'s) Rutes, 2000, as amended, . andthe
requirementsofthe D.G.Shippingor
thedevel opment,imPlementation
andcertificaiionofSMs issuedby the D.G.Shipping.
51 Theaboveinformaticnist'ueandconecta ndl am
d ulyauthorizedtomakethisdeclarationforandon
behalfofthe companY.
t./
Forandonbehalfofthe Owner/ BareboatCharierer: Forandonbehalfofthe ComPanY.

Name: flR. 06nPRK f\' DoBS'l Name: cAPT. GnnBWArs st4il,r

\ SiOn"tr*F\\\\\
Signature: \*U^^
Pffi&Date lt'/ flB A E I St I oS12y2 Place&Date..rt uPo 6 E / Z t po g l uts
Stamp: Stamp:
ffi %%.
ffim) kt Klla-ar$)
DGS/lSM-0 1 /Rev. 02 lMaY-1 4

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IvlS Notice 9 of ?A14 Page 77

 (Tobecompletedbyauthorizedrepresentatives ofthecompanyandalsoforreportingchanges)

1. VESSEL

NameofVessel: H P w6RK 8oA-f L Type ofVesssl' $o€cttl L fiu4 P oS /! J H Jf

OfficialNo. / CallSign: q56 J f vrn r lMoNumber:3q-++(38

2. PARTICULARSOFTI'IECOMPANY(lSMCode Ref':1.'t.2)
: OLLTA HAtT'.rLNE NdO .LNOUITTTLAL 5K.LLL 'TRALI'LN9
(Enclose certificateof lncorporation) -s r., r r LT- u.r ti p v T _ L T O .

COMPANYIDNo. 5tr8 0 6Uo

feSs; J'AJ.a tk l.toost BAutnD peratron OffEeAddress: oF f- Lct N o . lo 4
Pr00t.tr tLOoHE Apr. NA. 0vBp- 11(p,t ll* f Lo ok 1(LoT N o - 59 t 06l4A.t )f r-t
ouSe t AApo0O tTPe C."7,rtp.nR fArA
'j:.rorr0- , acao Lt- Ro A o , AAs PoN
l-.t

f-R ltoQSf.-, CARr.ta C Aort0f:R

NALLSa ?a RA -f:,xJT
r 0.iat _ I of^,Rgp(
1_o5 ctrtNctr Bu,tof A t rlONBAt ,NnraApptt"
ttA,-l4RAStl.t R A t, N D EA
P tN - 4oo oot.
Tel.No.: 11" 3 3o s Tel.No.:+Xt LL

E+nail.rracvia ?S evvi cc S@-dellc,,"a."i I ine' i n E-mail:no.vi 4c \(vu iceSAlell a-mevi I i n e .i n

3. DESIGNATED PERSON (lSM Code R.ef.: 4.0) (Enclose certified copy itt proof of
qualification,trainingandexperienae, inaccordance with MS Notice 09 of 2014)
DesignatedPerson: cApT. O un0wnu !tN$t' AlternateDesi gnated Person :

Name: CA2T B t"t A6 w Ft Jrn B t-r Name: cAPr. D tL B /\ 6 _srlv 6 tt

Position: D p A ^ Position: AOPF
ldentityDocument: 6 oC - tf 66- JL7-l ldentityDocument Co C- I f oo * l5 1- 6 |

OfficeAdllreSS: ro( , 1,,

(Placeofwork) nB...F.l f
LooA, pLof - 5g
srEf L yac)sf ff1""""11fr,Ti)
to 1, r Loo R, LoT " 59 "t t
6,qAcoA -sr Rc-f . AAHAI JTAf L HouSE,tlaRoOA SrAt E T
cA R n-A c 6u ie'a'::;3f fnfR PoV.r€4, CARn A c Avr\ OA A
^ ,:\njl, oun
llufl GA L, H Ar-r RnA.si.r.r an -qoo o o) cA an g6 Oolt Ot A , Ht) ABfi 3
Iynr+AAnst,{rR0 J 4oo oo9,
Tel.No.:-lg I LLq 173 4 o 46 Tel.No.:19; 2_L\s 7 g 2o t,6
MobileNo.: 14o53o344o MobileNo.:++gl AZ_a yo: g 6 o?_
FaxNo.: FaxNo.:
T^l^*hla TelexNo.:
I ct9 r rv..

E-mail: bhaq.^Jc.n't i oq h &Je I lunr" t I i rnc. i o E-mail: di lbaq . siay h &LJe I laprc,-v i t inrr' r

AOHTel. / FaxNos.: AOHTel. / FaxNos.:

4. I DENT IFICAT IO N OF H IG I.I EST LEVELOFMANAG EM EI\.IT(H L NN)

lr]ame:C6pT. S Ar tt C Name: cfrPr' 0LLBAg SrN gt.4

Position: RarA QrNq P-EAA cTBA Position: FO p A
ldentityDocument: Co C - Lto o - I 52_(
Tel.No.:43 1 ra-4: ZSZo l, ( Tel.No.: +gt ?*L
MobileNo.:.tg t 4 t 75 3 Ut,39 MobileNo.: +31 4Zog o38(o2-

MS Notice 9 of 20L4 Page 1"8

 Telex No.: Telex No.:
E-mail:Jo-lveey. Jing h @-Jel hnna' r{doo6, ia E-mail: Jilbcq , rinjh @.Jellc.nc.vi{ime,io
AOH Tel. / Fax Nos.: AOH Tel. i Fax Nos.:

s. BRANCH OFFICE(S)
Registered Name: Operation Office Address:
(Enclose certificate of lncorporation)

Registered Address:

Tel. No.: Tel. No.:

Fax No.: Fax No.:
Telex No.: Telex No.:
E-mail: E-mail:

l, the undersigned, hereby declare and state for and on behalf of the company that the company has been
incorporated and exists under the laws of the state and the officers of the company are those as indicate in the
enclosed list / below, the company does operate branch offices as mentioned below / does not operate branch
offices (strike if not applicable).
The above information is true and correct and I am duly authorized by the company and the aforesaid persons
to provide the aforesaid information.
(to be completed if a counter signature is required)

1.,lame:rcaz,
Sorrq Name
CI*, E@
_,'.ffi"
Srgnature:

ptace&Date:-
/
/r-n\ t/E/
?t "'q, E
v \f.,\_1,$),/
*,
4.\
\'--'t\
ll
U
Signature:

y_/
A
Date:
-,^aT-% hKtr
\\?\
)=
,.>
Place & /.9
rlu rt4r: r 4 stf orfffi,tT' Hu rl 0or 4 st f ol/2fu#
Certified by

Name & Stamp of the Registrar of Ship

FORM NO. DGS/ISM - 02/Rev.02lMay-14

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MS Notice 9 of 20L4 Page 19

 Form: ISM -11

We understand that the "Company" means the Owner of a ship or any other organization or person such as the
Manager, or the Bareboat Charterer, who has assumed the responsibility for oplration of the ship from the Ship
owner and who on assuming such responsibility has agreed to take over all the duties and responsibility
imposed by the ISM Code.
The undersigned affirms that:

Name of Company A0ct offSuoRE fRZ-vftTt LLHtTfO

Company lD No.
Address b(ftce No .o5, o38o fLooR, Reno.t rtoNl].-.t rfSqp(/L
llXt 0R. AN"VEL Bf-5pxT gofiO1 NoRLT-,tto1t 6p.a
Ptru'/,oo otNl LFDLA
Telephone Nos. +gl L,t-- lt(Loo3
FAX & E-mail ad c i o'l / t'^o {t 1t v v ql e &1 nu' I' c0,,,
t'

is the Owner of the following lndian registered Ship(s):

Ship Name Type of Ship Date of Port of Official Call tMo

and GT Build Registry Number Sign Number
n.P. w oRx Bo n r- L sP s +?y3 y 2oo I yott19AI
4 569 !'rAf 9z+149tr

ln accordance with Clause 3.1 of ISM Code, if the entity who is responsible for the operation of the ship is
other than the above stated Owner, the Owner must report the full name and details of such entity to the D.G.
shipping. lf such is the case here, the undersigned affirms with due diligence that:

Name of Company OE LTN HNR TTT HE P n O N6

f-r5-LrurC pUT.L.rD,
Company lD No. 5 S 8 o [?*o
Address loQ, ttr fLoo R,trloTrvo. S3,arg nal sTEli L t.toose
EaBoDA JTp6LT,TA-rA powlR, cnRNAL BoNOEtl
cr-{!^rcl"r t3oa O 0R ,l.4UH g R-]- _ o o so9, Lx os_ f).
Telephone Nos. I
+9 2?-/,9+57641
FAX & E-mail fiut i,,r(, te y v i ces @.dp I I c.rna", i t i*r e. i n

is the "Company" responsible for complying with all the requirements of the ISM code for the above
mentioned lndian registered Ship(s). The Company, for the purpose discharging its responsibilities thereof shall
be provided with all the necessary authority and support by the owners of these ships.
The undersigned further affirms that any change in "Company" must be made in writing by Fax or otherwise
within two (2)working days after such arrangement / agreement.

Signature: Title of top Management

Place: I-{ ung,AT rvftR JLdgtl
Date: Seal 3tlotf toZ3
Ref : DGS/ISM-l l/Rev.Ol/lVlav-14

MS Notice 9 of 20L4 Page29

 Form ISM-12

INTERNATTONAL SAFETY MANAGEMENT (tSM) CODE

DECLARATION OF DESIGNATED PERSON
FORM NO. DGS/ISM - 12
To ensure the safe operation of each ship and to provide a link between the "Company" and those on board,
every "Company" as appropriate shall designate a person or persons ashore having direct access to the
highest level of management. The responsibility and authority of the designated person or persons shall
include monitoring the safety and pollution prevention aspects of the operation of each ship and to ensure
that adequate resources and shore based support are applied, as required.
The undersigned affirms that and as an alternate assigned pursuant to IMO Resolution
MSC. 104(73), Section 4, of the ISM Code, as the "Designated Person(s)" for the following lndian registered
Ship(s) (Enclose documentary evidence showing that the designated person and the assistant / alternate
designated person (s) have the relevant qualification, training and experience as required under MS Notice 07 of
2014):
Type of Ship Date of Port of Official Call rMo
Ship Name
and GT Build Registry Number Sign Number
"f.p. wop6SoAf -3- sps 4 LgsS Loo I flvilgnI 4st3 \J Tp( ?L4+ 4rg

It is undertaken that the said "Designated Person(s)"will be available to the ISM cell of the Directorate
General of Shipping, Mumbai at any time.
The full address of the "Designated Person(s)" to which official correspondence and materials may be sent:
Nameof Company fi dAR.L"rLtlE A^tO LroosrRLAL SntLL rRn, ZNt'i. pt/7. LTD.
0€L'f
CompanylDNo.Address 5 8gO (ZO f t"4 , s7 VLooR f Lof . 59 FgttA't sTte L r+ou5f ,0ARaDA
Telephone No. / Mobilephone No. + 9 t q q o 33" 3 1 4 o
sf Rf- E'l

Fax number/ E-mail address bh a-7 wa-o' J ;'11 t' a- J e I I on oi'l

ine'' a

Name: cn e 7 ,sA6wnnr sTN9tt

Designation of .DPN
PtaceandDate: Seat: fltHBAi + JlloglZoz-S

The undersigned affirms and understands that any change in "Designated Person(s)" shall be intimated
to the D.G. Shipping immediately and all the correspondences received or made by Designated person are on
behalf of the

Signature:
(Title of Top nagbthent of Company)
Name: cAPf . rArvtt(R 52N96
Place and Date: ,'run64r * StloglLoz-s
Seal a-'i!.ror)

ay-|4

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MS Notice 9 of 2014 Page 30