A link to the Portable Document Format (PDF) of this form is provided below. The content of the form is duplicated in HTML following the PDF link.
- Name of shipping line (liner service only)
- Carrier code
- Report No.
- Name and description of ship
- Port of arrival/departure
- Date and time of arrival/departure
- Nationality of ship
- Name of master
- Port arrived from/Port of destination
- Certificate of registry (port; date; number)
- Name and address of ship's agent
- Gross registered tons
- Net registered tons
- Position of the ship in the port (berth or on station)
- Brief particulars of voyage (previous and subsequent ports of call; underline where remaining cargo will be discharged)
- Brief description of the cargo
- Number of crew (including master)
- Number of passengers
- Remarks / Attached documents (indicate number of copies)
- Cargo declaration
- Ship's stores declaration
- Crew list
- Passenger list
- Date and signature by master, authorized agent or officer
- Crew's effects declaration
- Maritime declaration of health
- Tonnage of cargo loaded/unloaded
- Containerized - Net weight
- Containerized - Unit of measure
- Non-Containerized - Net weight
- Non-Containerized - Unit of measure
- Number of containers
- 20' - Regular - Empty
- 20' - Half-height - Empty
- 40' - Regular - Empty
- 40' - Half-height - Empty
- Other (specify) - Empty
- 20' - Regular - Loaded
- 20' - Half-height - Loaded
- 40' - Regular - Loaded
- 40' - Half-height - Loaded
- Other (specify) - Loaded
- Type of service
- Conference line
- Independent line
- Vessels on charter (Yes /No) If yes, charter type
- Time Off
- Certificates (indicate expiry date)
- Safety construction (YYYY-MM-DD)
- Sanitation (YYYY-MM-DD)
- Loadline (YYYY-MM-DD)
- Safety equipment (YYYY-MM-DD)
- Safety radio (YYYY-MM-DD)
- Name of owner
- Summer dead weight tonnage
- Ship's overall length (to the nearest tenth of a meter (0.0))
- (a) Permission hereby granted to discharge cargo
(b) Clearance hereby granted for outward voyage
- Date stamp
Name of shipping line — If the arrival/departure is part of a liner service, then report the name of the shipping line. Leave blank for non-liner services such as ferries, tugs, barges, and other special services.
Field no. 1 — Name and description of ship — Record the registered name of vessel. Indicate if the vessel is a tug, barge, or ferry.
Field no. 8 — Name and address of ship's agent — Completed only where the agent completing this form is reporting the vessel under a carrier code assigned to another agent or carrier.
Field no. 13 — Brief description of the cargo — Indicate whether the vessel arrived/will depart in ballast or carrying cargo. For cargo carrying vessels provide a brief description of the type of load. If the cargo is in transit (neither loaded nor unloaded at the port), write "Cargo in transit" and the cargo tonnage carried in this field.
Field no. 16 — Remarks — Indicate if the vessel is involved in a specialized operation such as drilling, dredging, ice breaking, oceanography, or cartography. In the case of tug/barge operations, indicate the number of barges pulled. For a tug pulling one or more barges, record the name, nationality, and gross register tons of each barge. If a separate Form A6 is filed for each barge, it is not necessary to provide the information on name, nationality, and gross register tons of each barge on this form.
Field no. 24 A to D — Tonnage of cargo loaded/unloaded — Report the net weight and unit of measure of the cargo separating containerized cargo from all others. If the cargo is in transit (neither loaded nor unloaded at the port), leave field No. 24 A to D blank.
Field no. 25 A to J — Number of containers — If containerized cargo is reported in Field No. 24 A and B, complete Field No. 25 to show the actual number of containers, by length and height. For other than 20' or 40' containers specify the actual container size in addition to recording the number carried. Separate totals are required for empty and loaded containers of each size.
Field no. 26 — Type of service — Report the type of service by which the vessel is operating based on the following definitions:
- ship on a regularly scheduled service; includes conference line and independent (non-conference) service.
- such as tramp, oil tanker, product carrier, dry bulk.
- Conference line:
- ship on a regularly scheduled service provided by shipping lines which are grouped together in an association operating exclusively on a prescribed route(s) between countries.
- Independent line:
- ship on a regularly scheduled service operated by a shipping line which is not associated with other lines on a prescribed route(s) between countries.
Field no. 27 — Vessel on charter — Report whether the vessel is on charter. If on charter identify the terms of the charter. Check "voyage" if the vessel is chartered by trip or voyage. Check "bareboat" if the vessel has been chartered without crew. Check "time" if the vessel has been chartered on a time basis (by day, week, etc.).
Fields no. 28 to 32 — Self explanatory.
- Date modified: