BERTH/MOORING APPLICATION

BERTH/MOORING APPLICATION
UPON ACCEPTANCE, THIS FORM CREATES A BINDING CONTRACT

The contract comprises three parts:

PART 1: This Application ("Application Form")

PART 2: A communication from PAN accepting this Application Form

PART 3: The Standard Terms and Conditions
By submitting this form the Master warrants that:*

S/he has the authority to submit this Application Form and bind the Customer to the Standard Terms and Conditions in relation to the Vessel.S/he has received and read the Standard Terms and Conditions.The information in this Application Form is true and correct.
Application

Application is made by the Customer for berthing/mooring the following Vessel
Name of Vessel*
Customer (Master)*
Customer means the Vessel's Owner and the Vessel's Master
Customer (Owner)*
Customer means the Vessel's Owner and the Vessel's Master
Customer's Agent*
Contact Name*
Email*

Confirmation Emailexample@example.com
Phone Number*

Country CodeArea CodePhone Number
Arrival*

DayMonthYearHourMinutes
Departure*

DayMonthYearHourMinutes
Vessel Details
Flag*
IMO Number*
If no IMO number, please give official number
All equipment is operating satisfactorily and the Vessel is seaworthy*
All persons on board are fit for work and not suffering from any medical condition or communicable disease*
Since its last annual; survey, the Vessel has been subjected to any of the following: grounding, impact, fire, unapproved modifications or alterations, addition or removal of safety equipment, machinery or SFP *
P&I Club Name and Location*
H&M Underwriter*
H&M policy number 1*
H&M policy number 2
If applicable
H&M policy number 3
If applicable
Preferred Side
Port side at the discretion of Harbour Master / Pilot
GRT*
tons
Displacement*
tons
DWT*
tons
LOA*
metres
Beam*
metres
Deepest draft (actual)*
metres
Bow to bridge*
metres
Ship Security Officer*
Security Officer Contact

Country CodeArea CodePhone Number
Security Level of Vessel*
Current and last 10 ports of call. If security level has been different at any of last 10 ports of call, particulars must be given.
Last Port*
Next Port*
Services Required
Bunkers*
Immobilisation*
Water*
Hot Works*
Waste Disposal*
Submission
Signature

Clear
Customer's Agent
1. THIS APPLICATION FORM SHOULD BE SUBMITTED AT LEAST 48 HOURS BEFORE VESSEL ARRIVAL

2. An Inward Manifest must be submitted to PAN at least 24 hours before Vessel arrival.

3. An Outward Manifest must be submitted to PAN by the time the Vessel takes the berth.
Should be Empty:

BERTH/MOORING APPLICATION

Application

Vessel Details

Services Required

Submission