O’zbekiston avtomobil va daryo
transporti agentligiga
ARIZA – ANKYeTA
Kema to‘g‘risida ma’lumotlar:
1. Kema nomi: _________________________________________________________
2. Kemaning oldingi nomi, oldingi ro‘yxatga olgan joy va u bekor qilingan sana (agar ular mavjud bo‘lsa): ________________________________________________
_____________________________________________________________________
3. Kema joylashgan manzil _____________________________________________
4. Chaqiruv signali (aralash suzuvchi(daryo-dengiz) kemalar uchun) _____________
5. Suzishga yaroqli to‘g‘risidagi guvohnoma: _______________________________
(qachon, kim tomonidan berilgan, №)
_____________________________________________________________________
6. Turi va vazifasi: ___________________________________________________
7. Kema klassi: _______________________________________________________
8. Loyiha №: ______________ qurilgan yili va joyi ______________________
9. Qobiq materiali: ___________________________________________________
10. Bosh dvigatel ( turi, soni, umumiy quvvati): __________________________
_____________________________________________________________________
11. Kemaning gabarit o‘lchamlari: uzunligi ________m., eni _______m., to‘la yuk bilan suvga botishi _________m., bo‘sh holda suvga botishi ________m., bo‘sh holda suvga botishidan qurilmalari bilan eng katta balandligi ________m.. Belgilangan yuk ko‘tarish qobiliyati:_________t., yo‘lovchi sig‘imi __________kishi.
Kema egasi to‘g‘risida ma’lumotlar:
1. Korxona nomi ______________________________________________________
_____________________________________________________________________
2. Joylashgan manzili _________________________________________________
_____________________________________________________________________
3. Pochta manzili ______________________________________________________
_____________________________________________________________________
4. Telefon, faks (teleks, teletayp, e-mail) ________________________________
_____________________________________________________________________
5. Korxonaning davlat ro‘yxatiga olinganligi to‘g‘risidagi guvohnoma (pasport): seriya, № _________________
berilgan sanasi: ____________ kim tomondan berilgan: ____________________
6. INN: ______________________________________________________________
7. Mulkchilik shakli: _________________________________________________
8. Kemani ro‘yxatga olish uchun asos ______________________________________
(shartnoma turi, raqami, sanasi)
9. Kema mulk huquqi, cheklash ____________________________________________
_____________________________________________________________________
(shartnoma yoki hujjatning turi, sanasi)
10. Korxona (tashkilot) rahbari _________________ ____________________
(imzo) (F.I.Sh.)
M.O’.
20____y. «_____» ___________
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