Arrival		Departure	Page Number
	
1.1.	Name of ship	1.2.	IMO number	
1.3.	Call sign	1.4.  Voyage number	
2.  Port of arrival/departure	3.  Date of arrival/departure	
4.  Flag State of ship	5.  Last port of call/Next port of call	
6.  Number of persons on board	7.  Period of stay	
8.  Name of article	9.  Quantity	10.  Location on board	11.  Official use	

					

					

					

					

					
					
12.  Date and signature by master, authorized agent or officer