*To insert company/agent header as required

COMPANY’S DECLARATION

We hereby undertake to ensure all on-signing crew members comply with

MOH’s SHN guidelines1.

2 Periodical checks on the crew will be carried out by the company and any
deviation from the guidelines will be promptly notified to MPA.

Nationalit Passport Passport

No. Name Gender DOB
y no. Expiry
1
2
3
+ add more rows as required

Date of Crew Change

Application
Commencement Date of SHN
(Shall not be earlier than application date)
Completion Date of SHN
(Day 14)

Location of SHN

Ship Name

Ship Flag

IMO No.

Company Name
Company Responsible
Person
Contact Number

Ship Registered Owner

[Name and Signatory of Responsible [Name and Signatory of

Person] [Date] appointed PIC] [Date]

For the period of quarantine, the crew should abide by the “Health Advisory for Persons
[1]

Issued Stay-Home Notice” issued by MOH. 

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