(DHA-86) Form 41

APPLICATION BY MASTER OR OWNER OF SHIP OR AGENT REPRESENTING MASTER OR OWNER OF SHIP FOR CERTIFICATE TO LEAVE HARBOUR

[Section 7(1)(g) read with section 35(8); Regulation 34(12)]

I, ..............................................................................................................................................................(name(s) and surname of *master or owner of the ship/agent representing master or owner of the ship) hereby apply for a certificate to leave the harbour and declare that the following is a complete return of changes in the crew, passengers and others since arrival at this port:

CREW

Distressed seamen shipped

Passengers in transit:

List of stowaways on board:

.........................................................................................                              ..........................................................                                       ...................................................

Signature of person in charge of conveyance                                                              Date                                                                                                             Place

Name of conveyance: ...............................................................................................................................................

Registration No. .......................................................................................................................................................

Flag: .........................................................................................................................................................................

Name and surname of immigration officer ................................................................................................................

Appointment No: ......................................................................................................................................................

Signature: ................................................................................ Date: .......................................................................

Place .........................................................................................................................................................................