M/S Date

1. Name of device (merchanizm)

2. Maker-country

3. Type maker's No.

When built

4. Remarks:

	Very urgent (ship cannot		Urgent (required in		Planned (required for next dry dock or
	proceed without)		next port of call)		for normal operation)

No.	Name of spare parts	Code No or Fig No	Unit	Qty remaining	Qty required

Submitted Confirmed Approved

_________________ _________________ __________________

Chief of Dept. Master Superintendent


Note: To be completed when necessary and filed in both office's file and ship's file.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-TD05-F02 Page: 1/2

REQUISITION FOR SPARE PARTS NO.( )

QSMS PBO-TD05-F02 Rev. No.00

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