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Page 1 of 4
Contact Details
All fields are mandatory on this page
Authorising Flag State
-- Please Select --
Antigua and Barbuda
Aruba
Australia
Bahamas
Barbados
Belgium
Bermuda
Bolivia
Comoros
Cook Islands
Cyprus
Denmark
Dominica
Eritrea
Estonia
Finland
Germany
Gibraltar
Greece
Honduras
Iceland
Indonesia
Iran
Isle Of Man
Jamaica
Japan
Kuwait
Latvia
Liberia
Lithuania
Luxembourg
Madeira
Malta
Marshall Islands
Mauritius
Moldova
Myanmar
Netherlands
Netherlands Antilles
Norway
Portugal
Sierra Leone
Slovenia
St. Kitts & Nevis
St. Vincent and the Grenadines
Sweden
Syria
Tanzania
Thailand
Togo
Trinidad and Tobago
Tunisia
TZIRS Zanzibar
UK
Venezuela
If your Flag is not listed above, please contact us and we will request testing authorisation from your Flag.
Person to contact for testing
Contact Number
Contact Email
Billing Details
FMS Agent Number (if known)
Billing Company Name
Billing Address
Billing Country
Billing Email
Preferred Invoice Currency
-- Please Select --
GBP
USD
EUR
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Page 2 of 4
Vessel & Equipment Details
All fields are mandatory on this page
Equipment Type
Inmarsat C
Skywave
Satamatics
Iridium
Equipment Manufacturer : Model
Retrieving equipment list ...
--Select--
Not listed? Type here:
Equipment Serial Number
Type Approval Number
Inmarsat Mobile Number (IMN)
Inmarsat Serial Number (ISN)
IMEI Number
Vessel Name
Vessel IMO Number
Port of Registry
Distinctive Numbers or Letters
(call sign)
MMSI Number
Gross Tonnage
Sea Area Operation
A1
A2
A3
A4
Vessel Certificate Type
-- Please Select --
Cargo Ship Safety Certificate
Cargo Ship Safety Radio Certificate
Passenger Ship Safety Certificate
Other
Vessel Certificate Reference Number
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Page 3 of 4
Compliance Details
All fields are mandatory on this page
This equipment is additionally used for GMDSS
YES
NO
This equipment is additionally used for SSAS
YES
NO
This equipment is compliant with provisions of resolution A.694(17) and the equipment has been tested for electromagnetic compatibility (refer to resolution A.813(19))
YES
NO
This equipment is supplied with energy from the main and an emergency source of electrical power.
YES
NO
This equipment has an internal GPS or connected external GPS.
YES
NO
This equipment is type approved under the provisions of V/19-1.
YES
NO
This is a GMDSS terminal and therefore it is type approved under the provisions of IV/14.
YES
NO
This equipment is compliant with the requirements of IEC 60945 (2002-8) and IEC 60945 (2008-04).
YES
NO
This is the Ship Security Alert System (SSAS) and therefore complies with provisions of regulation XI-2/6 and resolution MSC.147 (77).
YES
NO
To the best of my knowledge the information I have given is accurate
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Page 4 of 4
Other Information
Fields on this page are optional, but may speed up your order
Radio Survey Renewal Date
Current Location at time of test
Atlantic Ocean West
Pacific Ocean
Atlantic Ocean East
Indian Ocean
Requested Testing Date
Any further comments:
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