MAIN INFO

OWNER'S NAME COUNTRY

CLASS NAME IMO
FLAG
TYPE OF SHIP SUPERSTRUC.LOCATION
SUPERSTRUC. COLOUR TYPE OF HULL
HULL COLOR
LOA BREADHT
MAX DRAFT FULLY LOADED MIN DRAFT LIGHT SHIP
GRT NRT
BALLAST WATER CAPAC. M3 MAX. FW CAPAC.
Nº OF FREEZE CHAMB. MAX. SEWAGE CAPAC. M3 HOW MANY
QTT OF BALLAST TANK AIT (Y/N)
INCINERATOR(Y/N) EQUIPMENTS & SECURITY PLAN(Y/N) ROOM FOR SOLID WA
HELIPAD(Y/N) WATER TREATMENT (Y/N) SELECTIVE WASTE COLLEC
SEWAGE TREATMENT (Y/N) HOW MUCH HOLDS VESSEL ARE? TEMPORARY DOCUMENT CERTIFI

EPIRB
NUMBER MMSI Nº
MANUFACTER OPERATIONAL SYSTEM
CALL SIGN DSC CALL
RADIOTELEX(Y/N) SART TRANSPONDER(Y/N) TRANSPONDER
RADIOTELEPHONY RADIOTELEGRAPHY

CERTIFICATES
NUMBER COUNTRY ISSUE DATE PORT EXPIRING DA
CERT. OF REGISTRY
ISPS CODE
SANITATION
SHIP`S GEAR CERTIFICATE

GENERAL INFORMATION - CREW INFORMATION

CREW LIST PLS SEND ATTACHED TO THIS MESSAGE THE CREW LIST STATED WITH FULL BELOW INFORMATION AND CREW EFFECT D

FULL NAME DOB NATIONAL. CITY SEX PASSPORT S'BOOK #

ON/OFF SIGNERS INFORMATION

FULL NAME RANK NATIONAL. DOB CITY PASSPORT S'BOOK #

PORTSTAY - BALLAST WATER

WILL BE THERE DEBALLAST? NO IS THERE BALLAST ONBOARD? NO

WAS IT EXCHANGED?
DRAFTS
AFT FWD
ARRIVAL M ARRIVAL M
SAILING M SAILING M

LAST PSC INSP. DATE DEFICIENCIES ?

COUNTRY

THERE ARE GUNS AND AMMUNITION ON BOARD? NO IF YES PLEASE SPECIFY

SANITARY INFORMATION - FRESH WATER

LAST FRESH WATER SUPPLY Last Disinsectization / Deratting (NOT SANITATION)
COUNTRY PLACE
PORT BY CREW?
DATE AND TIME DATE
QTTY OF PRODUCT USED

BALLAST WATER
TOTAL BW ON BOARD 0 MT TOTAL CAPACITY: MT

TANKS
B.W. MANAGEMENT PLAN ? YES NUMBER OF TANKS WITH B.W.: 0
IS IT IMPLEMENTED ? YES NUMBER OF TANKS WITHOUT B.W.: 16

OWN INT'NAL CONVENTION ? YES

IMO A.868 RESOLUTION ? YES

VESSEL INTEND TO DISCHARGE BALLAST WATER (Y/N) NO

VESSEL HAS BALLAST WATER (Y/N) NO
WERE THERE EXCHANGFE BALLAST WATER(Y/N)
OTHER ACTIONS WERE TAKE(Y/N) JUSTIFY WHY OTHER ACTIONS HAVE NOT BEEN REALIZED

BALLAST WATER REPORT PLS SEND THE BALLAST WATER REPORT ATTACHED TO
BALLAST WATER SOURCE BALLAST W. EXCHANGED - DILUTION (1) - FLOW THROUGH
Tank Date Port or Volume Temp. Salinity Date End point Volume
Holds dd/mm/yy Lat / Long dd/mm/yy Lat / Long

MARITIME HEALTH DECLARATION

IS THERE A SICK ANIMAL ON BOARD ? NO

DOES VESSEL PRODUCE DRINKING WATER ? NO

VESSEL WAS (OR PASSED THROUGH) AFFECTED AREAS AS PER WHO LAST REPORTS ? NO IF YES
TOTAL NUMBER OF SICK PERSONS DURING THE VOYAGE WAS HIGHER THAN EXPECTED ? NO
WERE MEDICINES USED DURING THE VOYAGE ? NO
HOW MANY PERSONS ARE SICK ? NIL
NAME OF THE MEDICINE USED N/A
WAS A DOCTOR CONSULTED ? NO
HAS ANY PERSON DIED DURING THE VOYAGE ? NO
WAS THERE A BURIAL AT SEA ? NO NUMBER OF BURIALS AT SEA
IS THERE ANY PRESENCE / DEATH OF RODENTS ON BOARD ? NO
WHERE ? COMPARTMENT NAME N/A
ANY SANITARY MEASURE WAS TAKEN (QUARENTINE, ISOLATION, DESINFECTION OR DECONTAMINATION) ?
WHAT KIND OF SANITARY MEASURE WAS TAKEN ?
PLACE OF SANITARY MEASURE WAS TAKEN ?
DATE OF SANITARY MEASURE WAS TAKEN
DATE: FUMIGANT NAME:
DESINFECTION / FUMIGATION OF CARGO OCCURED ? NO
ANY CASE OF DISEASES ON BOARD ? NO UNUSUAL BLEEDING (WITH OF WI
JAUNDICE ? NO SEVERE DIARRHOEA ?
COUGH OF SHORTNESS OF BREATH ? NO RECURRENT CONVULSIONS ?
ANY ACCIDENT OCCURED ON BOARD ? NO
WHAT KIND OF ACCIDENT ?

IS THERE A PSYCHOTROPIC AND/OR DRUGS LIST AVAILABLE ? NO FULFILL BELOW

NAME: SYMPTOM
WAS THERE ANY SUSPICIOUS OF INFECTIOUS DISEASE DURING THE IF YES
INTERNATIONAL VOYAGE ? WHEN SYMPTOMS
NAME: DATE:
IS THERE ANY SICJ PERSON ON BOARD AT PRESENT MOMENT ? IF YES
WHEN SYMPTOMS
NAME: DATE:
ARE YOU AWARE OF ANY CONDITION ON BOARD WHICH MAY IF YES
LEAD TO INFECTION OF SPREAD OF DISEASE ? WHEN SYMPTOMS
NAME: DATE:
WAS THERE ANY DEATH ON BOARD WHICH WAS NOT CAUSED BY IF YES
ACCIDENT ?

NARCOTIC LIST
DESCRIPTION ROB UNIT EXPIRING DATE

FITOZOOSANITARY INFORMATIONS

IS THERE ANY KIND OF VEG MATERIAL, SUCH AS LIVE PLANTS, PART OF PLANTS OR SEEDS ? NO IF YES
IS THERE DUST BEING TRANSPORTED BY THE SHIP ? NO IF YES
IS THERE ANY WOOD PACKAGING MATERIAL ONBOARD (E.G., PALLETS, SUPPORTS) ? NO IF YES
IS THERE ANY OTHER WOOD ARTIFACT TO BE DISCHARGED IN BRAZIL ? NO
DURING THE VOYAGE, HAVE YOU OBSERVED THE EXISTENCE OF PESTS ONBOARD ? NO
IS THERE ANY RESIDUES/WASTE OF ANIMAL OR VEGETAL FOR DESTRUCTION IN THE PORT ? NO
ARE THERE ANY DOMESTIC ANIMALS (E.G., DOGS, CATS, BIRDS) ? NO

WILL NEED FOR RESIDUOS DISPOSAL? NO IF YES WHAT KIND OF RESIDUES ? Selection
WHAT KIND OF RESIDUES ? Selection
WHAT KIND OF RESIDUES ? Selection
WHAT KIND OF RESIDUES ? Selection

PROVISION INFORMATIONS
DATE QUANTITY CHANDLER
RECEIVING FW L
FUEL L
LUBS L
DATE QUANTITY CHANDLER PROCESSIN
PROVISION Selection IF YES L/KGS Selection
TO RECEIVE L/KGS Selection
L/KGS Selection
L/KGS Selection

PROVISION LIST (PROVISIONS ONBOARD) PLS SEE THE BELOW EXAMPLE, SO PLS INSERT YOUR VESSEL PROVISION LIST OR SEND IT ATTACHED
STORAGE COMPARTMENT FOR DRY PROVISION? YES
TOTAL ITEMS NUMBERED

QUANTITY
ON BOARD PRODUCT NAME PROCESSING PACKAGE
IN NATURA BULK

ISPS INFORMATIONS

Name of Ship Name of Company

Type of Ship Address
IMO Number
Call Sign
Port of Register Flag

Name of Master

Name of CSO Means of Contact

Email 24hs Phone

Name of SSO Means of Contact

Email 24hs Phone

Name of Agent Means of Contact

Email 24hs Phone

Type of Certificate Issue Authority

Issue date Expire date

Ship Security Level

Is the Declaration of Security required? Yes/No no *If Yes, explain r

List of 10 Last Ports of Call* (*Please declare ports is in compliance with ISPS Code)

Port Name and Location (Country) ISPS Departure Date

NEXT PORT OF CALL ISPS ETA Next Port of Call

 HEIGH
MAX SPEED
DWT
RETENTION DAYS
W MANY KITCHENS?
PREPS (Y/N)
SOLID WASTE(Y/N)
E COLLECTION(Y/N)
T CERTIFICATE(Y/N)

MODEL
INMARSAT
INMARSAT Nº
PONDER 9GHz(Y/N)
NAVTEX(Y/N)

PIRING DATE

PLS SEND THE CERTIFICATE ATTACHED

FFECT DECLARATION

SB EXPIRY DATE RANK JOIN DATE CITY

EFFETCS (2 MOST
EXPIRY DATE EXPENSIVE ITEMS)

NO
 (Kgs / Liters)

CHED TO THIS MESSAGE

HROUGH (2) - EMPTY/REFIL (3) BALLAST WATER DISCHARGED
% Ench Depth (m) Exchange Date Port or Volume Salinity
Method dd/mm/yy Lat / Long

DATE: COUNTRY: PORT:

 NO

TH OF WITHOUT FEVER ? Selection

Selection
NS ? Selection

DID HE SEE
YMPTOMS: A DOCTOR? STATUS:
Selection Selection
MPTOMS STARTED? DID HE SEE
DATE: A DOCTOR? STATUS:
Selection Selection
MPTOMS STARTED? DID HE SEE
DATE: A DOCTOR? STATUS:
Selection Selection
MPTOMS STARTED? DID HE SEE
DATE: A DOCTOR? STATUS:
Selection Selection

WHAT'S ITS THE DESTINATION?

WHAT'S ITS THE DESTINATION?
 WHAT'S ITS THE DESTINATION?

E.T. QUANTITY
Selection
Selection
Selection
Selection

ROCESSING
Selection
Selection
Selection
Selection

CHED

PRODUCT
ORIGIN UNIT
KILO

Company
Contact Phone

Contact VHF Channel

Contact Phone
Means of Contact VHF Channel

hority LR

xplain reasons for DOS requisition on additional information