PORT OF FUJAIRAH NTM 148 Version 6

Attachment 2
17 January 2021

PRE-SAILING MASTER'S DECLARATION

Date
1. Vessel Name IMO Number
2. Flag Port of Registry
3. Vessel Type
4. LOA NRT GRT
5. Vessel arrival Condition Ballast Loaded Part Loaded
6. Last Port Next Port
7. Load Port (if other than Last Port)
8 If Next Port is one of UAE Ports YES NO
9. If - Yes - Mention Port The next final
Name destination Port after
UAE Ports
10 Purpose of Call Load Discharge Other (Please Specify)
11 If Bunkering Type Supplier Quantity
12 If Desloping Type Reciever Quantity
13. Type and Sl Type /Grade Load Discharge
aggregated
Cargo quantity 1)
(MT) loaded / 2)
Discharged in
Fujairah 3)

14. Terminals: Discharged to / Load from Discharged to : Load from :

15. Cargo Origin / Destination (NTM 225)

For Office Use Only

16. Vessel Rotation No. Berth

17 Vessel VIA No. Remarks

DECLARATION
I, ________________________________ the master of ____________________________
confirm & declare that no visitors / illegal persons onboard my vessel and I will ensure that
persons onboard will be strictly as per the crew list at the time of sailing.
The Information provided above is true as per my knowledge.

Shipping Agency Ship Master's Name

Agency Representative Name/Sign Ship Master's Sign

Company stamp Ship's stamp