Client Questionnaire ISM HSQEEn Code

Client Questionnaire- ISM/HSQEEn Code
(Information for Preparation of Estimate)
For a quick response, this questionnaire may be faxed or e-mailed directly to:
Fax: 1-281-877-6001 Fax: 30-210-9403610 Fax: 65-6275-0258 Fax: 86-21-6322-9649
(Americas) (Europe) (Pacific) (Greater China)
Email: [email protected] Email: [email protected] Email: [email protected] Email: [email protected]
1. General Information
PHYSICAL ADDRESS
Company Name Company IMO Number1
Address
City State or Country Postal Code
Contact Person Title
Phone Fax Email
BILLING / INVOICING ADDRESS ☐ SAME AS PHYSICAL
Company Name
Address
Phone Fax Email
CORRESPONDENCE ADDRESS ☐ SAME AS PHYSICAL
Company Name
Address
Phone Fax Email
1
Lloyd’s Register Fairplay issues unique Company Identification Numbers. For more information on obtaining this identification number visit
http://imonumbers.lrfairplay.com
MSC Administration MSC-JBA-00037 – Rev. 1 Page 1 of 5

MSC-PRI-00125
2. Company Shore-side Organization
Effective Number of Persons

Location M&R / Personnel /
Total Mgt./Admin Operations Technical Crewing
Head office:
Branch office:
Branch office:
Branch office:
Branch office:
3. Fleet Information
Fleet Breakdown by Vessel Type

Trade Routes
Crew Crew Working (Coastal/ Registries2
Vessel Type No. Size Nationality Language International) (Flag)
Passenger Ship
Passenger High Speed Craft
Cargo High Speed Craft
Bulk Carrier
Oil Tanker
Chemical Tanker
Gas Carrier
Mobile Offshore Drilling Unit
Other Cargo Ship:
Other Cargo Ship:
Other Cargo Ship:
Other Cargo Ship:
Fleet Breakdown by Class Society

Society ABS DNV LR BV NK GL RINA Others:
Number of 3
Vessels
2
Flag of Registry
MSC-PRI-00125
Vessel Information
Vessel
Vessel Name Vessel Type Class No.
IMO No.

MSC-PRI-00125
4. Planning Information
Projected Date:
Manual Review:
Interim Certification Audit:

Initial Certification Audit:
5. ISM Certification
Certificates granted under the program include an ISM Document of Compliance (DOC) for the shore side
operation and ISM Safety Management Certificates (SMCs) for each ship. The DOC will be issued upon
satisfactory completion of the office assessment process. Subsequently, SMC’s will be issued to individual ships
upon successful assessment. Certificates are issued for a five year term.
☐ Please provide “Application for Marine Management System Certification" with an estimate for the
requested service.
6. Optional Certification Scheme
ABS also offers certification to ABS Guide for Marine Health, Safety, Quality and Environmental and Energy
Management (HSQEEn Guide) in conjunction with ISM Code certification. The HSQEEn Guide is designed to
meet or exceed the requirements of the ISM Code, ISO 9001, ISO 14001, ISO 50001 and OHSAS 18001
standards. Upon certification, ABS issues the following certificate(s) and/or Notation(s):
a. Certificate of Company Compliance – indicating company compliance with applicable requirements of ABS
HSQEEn Guide is issued for a period of five years.
b. Certificate of Vessel Compliance – indicating vessel compliance with applicable requirements of ABS
HSQEEn Guide is issued for a period of five years.
c. Notation – issued to ABS-classed vessel to recognize that it conforms to the designated requirements of
HSQEEn Guide.
Yes No
Does your Company want certification to the ABS Guide?
Certification Information:
In addition to the minimally required Safety “S” Certification under the Guide, please indicate if your company
would like any of the other certification options listed below:
Q (Quality) E (Environmental) En (Energy) H (Health)
Note: Pre-assessment (STAGE 1) is required for Q, E, H or En certification.

MSC-PRI-00125
Additional Information for Energy (En) Certification:
a) Total amount of energy used annually in BBTUs:
b) Total number of energy sources within the scope of certification:
Check all Energy Heavy Fuel Marine Marine Gas Other

sources that Natural Gas Electricity Oil Diesel Fuel Fuel (please specify)
apply
Shore based:
Shipboard:
c) List Significant Energy Uses:

d) Scope & Boundary of EnMS Certification
7. Optional Accredited ISO Certification

As an alternative to the ABS HSQEEn Guide certification, ABS Quality Evaluations (ABS QE) offers accredited
ISO certification. The schedule of fees for this service can be provided by ABS QE upon request.
Yes No
Would you like ABS QE to contact you for the accredited certification?
ABS Use Only Division Reviewed By:

Received By:

MSC-PRI-00125

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Client Questionnaire- ISM/HSQEEn Code

(Information for Preparation of Estimate)

Company Name Company IMO Number1

City State or Country Postal Code

Contact Person Title

Phone Fax Email

BILLING / INVOICING ADDRESS ☐ SAME AS PHYSICAL

City State or Country Postal Code

Contact Person Title

Phone Fax Email

CORRESPONDENCE ADDRESS ☐ SAME AS PHYSICAL

City State or Country Postal Code

Contact Person Title

Phone Fax Email

MSC Administration MSC-JBA-00037 – Rev. 1 Page 1 of 5

2. Company Shore-side Organization

Effective Number of Persons

Fleet Breakdown by Vessel Type

Fleet Breakdown by Class Society

MSC Administration MSC-JBA-00037 – Rev. 1 Page 3 of 5

Interim Certification Audit:

6. Optional Certification Scheme

Q (Quality) E (Environmental) En (Energy) H (Health)

Note: Pre-assessment (STAGE 1) is required for Q, E, H or En certification.

MSC Administration MSC-JBA-00037 – Rev. 1 Page 4 of 5

Additional Information for Energy (En) Certification:

a) Total amount of energy used annually in BBTUs:

b) Total number of energy sources within the scope of certification:

Check all Energy Heavy Fuel Marine Marine Gas Other

c) List Significant Energy Uses:

7. Optional Accredited ISO Certification

ABS Use Only Division Reviewed By:

MSC Administration MSC-JBA-00037 – Rev. 1 Page 5 of 5

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