_______________________________________________________________________________

   船名            國(guó)籍              船籍港                  所有人

  Ship____       Nationality_____  Port of Registry_____  Ship's Owner or Chatterer_____

  總噸位         凈噸位             載重噸位             貨物噸數(shù)       噸

  Gross Tonnage__  Net Tonnage____  Deadweight Ton____ Import Cargo_____Tonnage____

    通運(yùn)貨物  噸  指運(yùn)中國(guó)其他港口貨物  噸 沒(méi)有列入載貨清單或沒(méi)有提單的貨物

    Through  Tons  Cargo Destined for  Tons  Cargo Un-manifested or Without

    Cargo____    Other Chinese Port（s）______  Bill of Lading：_____

    出發(fā)港       出發(fā)日期                 經(jīng)過(guò)港             抵達(dá)本港時(shí)間

    First Port of    Date Of                   Last             Date and TimeOf

  Present Voyage____ Departure______         Port______    Arrival at This Port________

                                       公尺                         公尺

  船舶吃水前                       _______船舶吃水后

                         尺                           尺

    Draft F .______________m／ft．A ._____________m／ft．

_______________________________________________________________________________

    1．港內(nèi)禁用物品報(bào)告單一份

    Report on Articles Restricted for Use in Port..................1 Copy

    2．船員名單四份Crew List...................4 Copies

    3．旅客名單四份（包括通運(yùn)旅客，沒(méi)有旅客免報(bào)）

    Passengers .....................4 COpies（Passenger List-Inward and／or

Through，Not required if not carrying passengers）

    4．進(jìn)口載貨清單一份    Import Manifest ...............1 Copy

    5．船員自用和船舶備用物品，貨幣，金銀清單一份（來(lái)自中國(guó)港口免報(bào)）

    List of Specified Articles，F(xiàn)oreign Currencies，Gold，Silver Belonging to

Ship and／or Members Of Crew ..................1  COpy（Not required of ship

arriving from Chinese port）

    6．航海健康申明書一份（來(lái)自中國(guó)港口免報(bào)）

    Maritime Declaration of Health ............. 1 Copy（Not requiredofship

arrivingfrom ChinesePort）

    7．其他文件    Other Papers

_______________________________________________________________________________

呈驗(yàn)文件：Paperssubmitted herewith for examination）：

1．國(guó)籍證書                          Certificate of Nationality

2．噸位證書                          Tonnage Certificate

3．適航證書                          Navigation Certificate

4．乘客定額證書                      Passenger Certificate

5．載重線證書                        InternatiOnal Load-line Certificate

6．除鼠或免予除鼠證書                De—ratting or De-ratting

                                     Exemption Certificate

7．航海日志                          DeckLogBook

8．機(jī)艙日志                          Engine Log Book

9．噸稅執(zhí)照或使用牌照完稅證          Tonnage Dues Certificate

10．指運(yùn)中國(guó)其他港口的貨物清單       Manifest of Cargo Destined

                                     for Other Chinese Port（s）

11．由外國(guó)裝載運(yùn)往國(guó)外的貨物清單     Manifest of Cargo Shipped From and

                                     Destined for Foreign Port（s）

12．其他                             Other Papers

茲聲明：本報(bào)告書所有各項(xiàng)均準(zhǔn)確無(wú)訛。

    I hereby declare that the particulars entered on this form are true and correct.

    此致

中華人民共和國(guó)    港 務(wù) 監(jiān) 督

海       關(guān)

邊防檢查站

衛(wèi)生檢疫所

To _____ Harbor Superintendence Administration

    Customs Houseof                                  of the People's

    Frontier Defense Inspection Station                    Republic of China

    Quarantine Service

船長(zhǎng)簽字                    

Captain（Signature）___________

日期                        

Date ____________________