_______________________________________________________________________________

   船名            国籍              船籍港                  所有人

  Ship____       Nationality_____  Port of Registry_____  Ship's Owner or Chatterer_____

  总吨位         净吨位             载重吨位             货物吨数       吨

  Gross Tonnage__  Net Tonnage____  Deadweight Ton____ Import Cargo_____Tonnage____

    通运货物  吨  指运中国其他港口货物  吨 没有列入载货清单或没有提单的货物

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

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

    出发港       出发日期                 经过港             抵达本港时间

    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．港内禁用物品报告单一份

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

    2．船员名单四份Crew List...................4 Copies

    3．旅客名单四份（包括通运旅客，没有旅客免报）

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

Through，Not required if not carrying passengers）

    4．进口载货清单一份    Import Manifest ...............1 Copy

    5．船员自用和船舶备用物品，货币，金银清单一份（来自中国港口免报）

    List of Specified Articles，Foreign Currencies，Gold，Silver Belonging to

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

arriving from Chinese port）

    6．航海健康申明书一份（来自中国港口免报）

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

arrivingfrom ChinesePort）

    7．其他文件    Other Papers

_______________________________________________________________________________

呈验文件：Paperssubmitted herewith for examination）：

1．国籍证书                          Certificate of Nationality

2．吨位证书                          Tonnage Certificate

3．适航证书                          Navigation Certificate

4．乘客定额证书                      Passenger Certificate

5．载重线证书                        InternatiOnal Load-line Certificate

6．除鼠或免予除鼠证书                De—ratting or De-ratting

                                     Exemption Certificate

7．航海日志                          DeckLogBook

8．机舱日志                          Engine Log Book

9．吨税执照或使用牌照完税证          Tonnage Dues Certificate

10．指运中国其他港口的货物清单       Manifest of Cargo Destined

                                     for Other Chinese Port（s）

11．由外国装载运往国外的货物清单     Manifest of Cargo Shipped From and

                                     Destined for Foreign Port（s）

12．其他                             Other Papers

兹声明：本报告书所有各项均准确无讹。

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

    此致

中华人民共和国    港 务 监 督

海       关

边防检查站

卫生检疫所

To _____ Harbor Superintendence Administration

    Customs Houseof                                  of the People's

    Frontier Defense Inspection Station                    Republic of China

    Quarantine Service

船长签字                    

Captain（Signature）___________

日期                        

Date ____________________