Arrival		Departure	
1.1.  Name and type of ship
	1.2.  IMO number
	
1.3.  Call sign
	1.4.  Voyage number	
2.  Port of arrival/departure	3.  Date and time of arrival/departure
	
4.  Flag State of ship
	5.  Name of master
	6.  Last port of call/Next port of call	
7.  Certificate of registry (Port; date; number)
	8.  Name and contact details of ship’s agent	
9.  Gross tonnage
	10.  Net tonnage
		
11.  Position of the ship in the port (berth or station)
		
12.  Brief particulars of voyage (previous and subsequent ports of call; underline where remaining cargo will be discharged)

	
13.  Brief description of the cargo

	
14.  Number of crew
	15.  Number of passengers
	16.  Remarks	
Attached documents
(indicate number of copies)		
17.  Cargo Declaration
	18.  Ship’s Stores Declaration		
19.  Crew List
	20.  Passenger List
	21.  The ship’s requirements in terms of waste and residue reception facilities	
22.  Crew’s Effects Declaration (only on arrival)
	23.   Maritime Declaration of Health (only on arrival)		
24.  Date and signature by master, authorized agent or officer