| | | Arrival | | Departure | |
| 1. Name and description of ship | 2. Port of arrival / departure | 3. Date - time of arrival / departure |
| 4. Nationality of ship | 5. Name of master | 6. Port arrived from / Port of destination |
| 7. Certificate of registry (Port, date, number) | 8. Name and address 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 (incl. master) | 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. Date and signature by master, authorized agent or officer |
| 22. Crew's Effects Declaration <*> | 23. Maritime Declaration of Health <*> | |