Page Number	
1.1.	Name of ship
	1.2.	IMO number
	
1.3.	Call sign
	1.4.	Voyage number	
2.  Flag State of ship
		
3.No.	4.Family name, given names	5.Rank or rating	6. Effects ineligible for relief from customs duties and taxes or subject to prohibitions or restrictions*	7.  Signature	

					

					

					

					

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