| 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: | |||||||
| No. | Family name | Given names | Nationality | Date of birth | Place of birth | Identity document (Type, No., Expiry) | Port of embarkation | Port of disembarkation | Transit passenger (Y/N) |
|---|---|---|---|---|---|---|---|---|---|
| 7. Date of issue: | 8. Signature and rank of master, authorized agent or officer: | ||||||||