Ministry For Primary Industries

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Port State Measures Inspection

• Inspection Report No.

• Port State: New Zealand

• Inspecting Authority: Ministry For Primary Industries

• Name of Principal Inspector

• Inspector Warrant Number

• Port Of Inspection

• Commencement of Inspection

  Date

• Advanced notification received

  Yes

  No

  N/A

• Purpose

  LAN

  TRX

  PRO

  OTH

• Last Port of Call

• Port

• State

• Date

  Date

• Vessel Name

• Flag State

• Type of Vessel

• International Radio Call Sign

• Certificate of Registry ID

• Certificate of Registry photo

  Media

• IMO Ship ID (if Available)

• External ID (if Available)

• Port of Registry

• Vessel Owners

• Vessel Beneficial Owner(s) if Known and Different to Vessel Owner

• Vessel Operator(s) if Different to Vessel Owner

• Vessel Master

• Name

• Nationality

• Photo of Master and ID

  Media

• Fishing Master

• Name

• Nationality

• Photo of Fishing Master and ID

  Media

• Vessel Agent

• Vessel Monitoring System

  No

  Yes: National

  Yes:RFMOs

  Type:

• Status in Regional Fisheries Management Organisations (RFMO) Areas Where Fishing or Fishing Related Activities Have Been Undertaken, Including Any Illegal Unreported Unregulated (IUU) Vessel Listing

Vessel Status

• Vessel Identifier

• RFMO

• Flag State Status

• Vessel on Authorised Vessel List

• Vessel on IUU Vessel List

• Relevant Fishing Authorisation(s)

Fishing Authorisation

• Identifier

• Issued By

• Validity

• Fishing Areas

• Species

• Gear

• Relevant Transhipment Authorisation(s)

Transhipment Authorisation

• Identifier

• Issued By

• Validity

• Transhipment Information Concerning Donor Vessels

Donor Vessel

• Name

• Flag State

• ID No

• Species

• Product Form

• Catch Areas

• Quantity

• Evaluation of Offloaded Catch (quantity)

Offloaded Catch

• Species

• Product Form

• Catch Area(s)

• Quantity Declared

• Quantity Offloaded

• Difference Between Quantity Declared and quantity determined, if any

• Catch Retained On Board

Retained On Board

• Species

• Product Form

• Catch Area(s)

• Quantity Declared

• Quantity Offloaded

• Difference Between Quantity Declared and quantity determined, if any

• Examination of Logbook(s) and other Documentation

  Yes

  No

  N/A

• Compliance With Applicable Catch Documentation Scheme(s)

  Yes

  No

  N/A

• Compliance With Applicable Trade Information Scheme(s)

  Yes

  No

  N/A

Type of Gear Used

• Gear Examined in Accordance With Paragraph e of Annex B

  Yes

  No

  N/A

• Seabird Mitigation Devices on Board

  Yes

  No

  N/A

Findings

• Apparent Infringement(s) Noted Including Reference to Relevant Legal Instrument(s)

• Comments by the Master

• Action Taken

• Master's Signature

  Sign

• Inspector's Signature

  Sign