Vessel Declaration Form - Haldia Dock Complex

Received by: Vessel Declaration Form For official useTime: Kolkata Port Trust Date:Vessel Operation No[fill up by Marine officials]: ___________________________1. Vessel Name: ______________________________________________________________2. Type: M.V./M.T. Call Sign: ___________________________3. Regn./Official No.: __________________ Port of Regn. __________________________4. Owner' Name: _____________________________________________________________5. Address: __________________________________________________________________6. P & I Club e-mail address: ____________________________________________________7. No. of Hatches: a) _______________ b)_____________ c) ____________ d)____________8. Capacity & details of Crane/Derricks____________________________________________9. BP Length: ______(Mtr.) 10. LOA: ___________(Mtr.) 11. Beam: ___________(Mtr.)12. GRT: ________________________(MT) 13. GRT reduced[if any]: ____________(MT)14. NRT: ________________________(MT) 15. DWT : ________________________(MT)16. Speed: _______________________ 17. Nationality/Flag_____________________18. Vessel Master Name: ________________________________________________________19. Owner's Agent: _____________________________________________________________20. Operation Type: Mother/Daughter/Feeder 21. Voyage Type :Liner/Charter/Tramp22. Name of Charterer/Conference: ________________________________________________23. Purpose of Journey: Import/Export/Import & Export/Others [specify] __________________24. Rotation No.[if any] Import:_____________________ Export: ______________________25. Vessel under : Foreign Run/Coastal Run26. Cargo Bound-ness: Excise/Custom/Both (Excise & Custom)/Un-bound/Ballast [No cargo]27. Whether it is a Substitue Vessel? No/Yes. If ‘Yes’ then give original Von:__________ &Vessel Name:_______________________________________________________________28. Number of Crew [Indian]: ____________________ [Non-Indian]: ___________________29. Number of Officer: __________ ________________ Non-Officer: ___________________30. Number of Pakistani National [if any]: __________________________________________31. Expected Arrival Date: _____/_____/______[DD/MM/YYYY] Time: __________[HH:MM]32. Whether this call to Haldia is a part of same Voyage? No/YesIf 'Yes' please give the last Haldia arrival date: _____/_____/______[DD/MM/YYYY].33. Requested Call-ins Normal/on Priority/ .34. Last Port: __________________________ 35. Next Port: ___________________________36. Original Port: _______________________ 37. Destination Port: _____________________Place:_________________________Date: _________________________Agent' Signature with SealDesigned by: Nicsi

Note: - Please attach the following documents.1. P&I Certificate.2. ISM Certificate.3. ISPS Documents including Last Ten Ports of Call.4. Crew List.5. CAP Certificate if applicable.6. Declaration by the Master regarding willingness to double bank.