| 1. Name of ship: | 2. IMO No.: | 3. Call Sign: | |||||
| 4. Port of arrival/departure: | 5. Date of arrival/departure: | 6. Flag State of ship: | |||||
| 7. Last port of call: | 8. Next port of call: | ||||||
| No. | Family name | Given names | Rank or rating | Nationality | Date of birth | Place of birth | Identity document (Type, No., Expiry) |
|---|---|---|---|---|---|---|---|
| 9. Date of issue: | 10. Signature and rank of master, authorized agent or officer: | ||||||