Maritime Health Clearance Request Form
Vessel Name
IMO Number
Flag State
Gross Tonnage
Port of Arrival
ETA (Date & Time)
Last Port of Call
Date of Departure
Number of Crew Onboard
Number of Passengers Onboard
Any illnesses reported during voyage?
No
Yes
If yes, please specify
Declaration by Master/Authorized Officer
Name
Rank
Date
Signature