To : ____________ Attached please find_________copies of document. You are kindly asked to sign the receipt and keep the document properly.

S/N	Name of documents	Pages	Edition

................................................................................................................................................................

Acknowledgment of Receipt on board	Acknowledgment of Receipt in Office
Date Receipt : Master__________________________________ (Signature) Vessel :_________________________________	Date Receipt : Receiver :_______________________________ (Signature) Division :_______________________________

DPA :_____________________

Note: To be completed every time and filed office's file.

To retain for 1 year.

Issue date: 03.11.2003/Rev. 00 PBO-G∗04-F04 Page: 1/1

RECEIPT OF DOCUMENT TRANSMITTAL

QSMS P-G∗04-F04 Rev. No.00

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