Special Health/Medical Declaration for Vessels Arriving Chittagong

Is ships Have you

Is any Ships Any crew
master and visited any How many
crew is sick ? change in Do you
crew arc Coronavirus Crews
Vessel Name (If yes then Last 5 Port of last 1 need any ETA/Arriv
free affected onboard and
SI & what kind of Calls month ? (If medical al Time and
from Countries (in Nationality
FLAG Sickness & (With Date) yes assistance Date
Coronavirus last 15 Of
Nationality Nationality ?
? days) ? crews
Of Crew) of Crews)
(YES/NO) (YES/NO)

1. MT. JI TAI YES NO ALL NEW CREW NO 13 CREWS NO NO 10.OCT.2021

& QUARANTINE AT HOTEL 12 DAYS IN BATAM &
MONGOLIA INDONESIAN

Signature of Master/Captain

Name: Capt.Iskandar Zulkarnain

Date: 02.10.2021