TO
BE FILLED AND SUBMITTED BY THE AGENTS EVERY VOYAGE AT LEAST THREE WORKING DAYS
PRIOR TO THE VESSEL'S ARRIVAL IN
THE PORT OF MUMBAI AND SHOULD BE SUBMITTED TO THE DEPUTY CONSERVATOR'S OFFICE AT
THE “PORT HOUSE” OR AT THE “OPERATION SERVICE CENTER”.
1.Vessel’s
Name ___________________________ 2.
Call Sign __________
3.
Line Code : ________ 4. Rotation
Number__________Rotation Date____________
5.
IGM Number ____________________ IGM
Date ____________
6.Agents Name _____________________________________________
7.Name of the Master_________________________________________
8.Purpose of Visit____________9.ETA Mumbai _________ 10.ETD Mumbai ________
11.Present Displacement (For Tankers)____________________
12. Arr. Draft F_______ A _______ 13. Freeboard at this Draft___________
14. G.R.T. __________ 15. N.R.T. __________16. LOA __________17. LBP_________
18. Exptd. Dep. Draft F________ A _________
19. Exptd. Dep.Displacement (For Tankers) _____________
20. Whether same bottom cargo (For J.D.) : Yes / No
21. If Yes , Details ____________________________________________________
22. Last Port _________________ 23. Dep. Dt. & Tm.__________
24. Next Port _________________ 25.ETA Next Port ___________
26. Last Ten Ports Visited _______________________________________________
__________________________________________________________________
27. No. of times the vessel has visited Mumbai port in the last six Months _______
28. Cargo on board Type ________________ Qty : Hold_________ Deck _________
29. Cargo to disch in Mumbai Type _______ Qty : Hold_________ Deck _________
30. Cargo to load in Mumbai Type _______ Qty : Hold_________ Deck _________
31. Crew on board Indian ______________ Non-Indian______________________
32. Passengers on Board : Total ___________ ; Cabin _________
33. No. of Passengers to Embark / Disembark _____________
34. Hazardous Cargo on board Yes / No
35. If Yes, (a) IMO class ___________ (b) Mb.P.T Category A / B / C / D
36. Vessel’s Requirements in the port of Mumbai
(a) Floating Crane : Yes / No
(b) Fresh Water : Yes / No Qty. _________
(c) Bunkers : Yes / No. (H.O) Qty _______ (D.O) Qty. ______
(d)Sludge Disposal : Yes / No
37. Whether coming From Yellow Fever Area Yes/No.
38. Whether Stowaway on board Yes / No
39. Whether Double banking Required Yes / No.
40. Whether Lighterage Operation Required Yes / No
41. Name of P&I Club __________________________
42. Local Correspondent________________________
43. Name of Hull & Machinery Insurance Company__________________________
We hereby undertake to pay to the port trust, all pilotage charges, port dues, tug hire, berth hire, idle charges and fresh water charges for the services required by the vessel, while in the port.
Signature_____________________________
Name _______________________________