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MPM - 6.21a - Onboard - Complaint - Form - Marshall Island

This 3-page document is an on-board complaint form to be filled out by a complainant officer or their representative regarding any complaints on the vessel. It includes sections for the ship's particulars, complainant's particulars, witness particulars if applicable, a section to describe the complaint, a declaration, and sections to document any meetings or resolutions regarding the complaint. Contact information is also provided for handling the complaint with the company and relevant authorities.

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Mervin John
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387 views3 pages

MPM - 6.21a - Onboard - Complaint - Form - Marshall Island

This 3-page document is an on-board complaint form to be filled out by a complainant officer or their representative regarding any complaints on the vessel. It includes sections for the ship's particulars, complainant's particulars, witness particulars if applicable, a section to describe the complaint, a declaration, and sections to document any meetings or resolutions regarding the complaint. Contact information is also provided for handling the complaint with the company and relevant authorities.

Uploaded by

Mervin John
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

MPM 6.

21A
Rev 01 / 2022-03-31
Page 1 of 3

On-Board Complaint Form


This form is to be filled by the complainant officer or complainant’s representative. If the
complaint involves allegation against any other officer or seafarer, which may be regarded as
personal, private or intimate, such seafarer may not be referred to in an identifiable way in
writing this form.
Ship’s Particulars
Vessel: Date: Place:

Complainant’s Particulars
Designation: Name and Passport No: Date of Birth:

Witness/Representative’s Particulars (if any)


Designation: Name and Passport No: Date of Birth:

Complainant’s Witness/Representative’s Declaration:


I confirm that I have agreed and accepted to accompany and/or to represent the complainant
officer, and to attend any meetings into the subject matter of the complaint.

Signature : ________________________________________________________

Briefly describe the complaint (including date, time and place of event and persons involved or
witnesses):
MPM 6.21A
Rev 01 / 2022-03-31
Page 2 of 3

Declaration:
I confirm that I have not been penalised or victimised in any way for filing this complaint, and
that I have been informed that lodging this complaint is without prejudice to my right to seek
redress through whatever legal means I consider appropriate.

I declare that all the information submitted by me in this On-Board Complaint Form is correct
and does not contain any false information. I declare that I have not omitted any relevant
information and that my complaint is not unjustified.

I accept that this matter may be referred to the Master for resolution and the Master will inform
me of the outcome.

Signature of the complainant:


________________________________________________________

Acknowledged by Head of Dept, Seafarer’s Superior Officer or Shipmaster


Rank: Name: Date of Receipt:

Meeting to Resolve Complaint


Date Of Meeting & Attended By

Briefly describe the result of the meeting

The matter has been resolved: Yes / No (If No, please state reason)
MPM 6.21A
Rev 01 / 2022-03-31
Page 3 of 3

If No – The matter has been referred to the Company for resolution on


(date/month/year). If other, please state organisation.

Acknowledged by Complainant. Signature by Shipmaster


Name and Signature: Name and Signature:

Date: Date:
Acknowledged by Complainant’s
Witness/Representative

Name and Signature:

Date:

Contact information of the person/persons designated by the MLC Shipowner


A
for handling on-board complaints:
a. Name Ms Annula Perera

b. Telephone number +65 85185065

c. Email address annula@cst-shipping.com.sg / crewing@cst-shipping.com.sg

Contact information of the Flag State ( ) Office:


B
*Please refer to Contingency Manual (CM) – LC 7 for Flag State Contact

a. Telephone number

b. Email address

c. Website
Contact information of the competent authority in the seafarers’ country of
C residence:
*To be provided by the Manning Agent

a. Name

b. Telephone number

c. Email address

Note: Please refer to On-board Complaint Procedures in MPM 6.21.

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