GENERAL DECLARATION

(IMO FAL Form 1)

✓ Arrival Departure

1.1 Name and type of ship 1.2 IMO number

M.T PACIFIC GRAY (Tanker, Oil) 9613616
1.3 Call sign 1.4 Voyage number
3FVO6 01/09
2. Port of arrival/departure 3. Date and time of arrival/departure
Maptaphut, Thailand January 01, 2019 at 0100H
4. Flag State of ship 5. Name of master 6. Last port of call/Next port of call
PANAMA Capt. Greg Demyanosky Cebu, Philippines
7. Certificate of registry (Port; date; number) 8. Name and contact details of ship's agent
PANAMA 25/12/18, 1234 TBA
9. Gross tonnage 10. Net tonnage
7,721 t 3,740 t
11. Brief particulars of voyage (previous and subsequent ports of call; underline where remaining cargo will be
discharged)
Last port was Mailiao, Taiwan next port to go is Cebu, Philippines but the remaining cargo
will be discharged at Maptaphut, Thailand

12. Brief description of the cargo

ULSD – 10,000 MT

13. Number of crew 14. Number of passengers 15. Remarks

10 NIL
Attached documents
(indicate number of copies)
16. Cargo Declaration 17. Ship's Stores
Declaration
18. Crew List 19. Passenger List 20. The ship's requirements in terms of waste and
residue reception facilities
21. Crew's Effects Declaration (only 22. Maritime
on arrival) Declaration of
Health (only on
arrival)
23. Date and signature by master, authorized agent or officer

For official use

 CREW'S EFFECTS DECLARATION
(IMO FAL Form 4)

Page Number

1.1 Name of ship 1.2 IMO number

M.T PACIFIC 9613616
1.3 Call sign 1.4 Voyage number
3FVO6 01/09
2. Flag State of ship
PANAMA
3. 4. Family name 5. Given 6. Rank or rating 7. Effects ineligible for relief from 8.
No. names customs duties and taxes or Signature
subject to prohibitions or
restrictions

1 Demyanosky Greg Master 1 Laptop, 1 Mobile Phone,

1 Camera
2 Kosaruv Sergei Chief Officer 1 Laptop, 2 Mobile Phones
3 Ramos John Brian 2nd Officer 1 Laptop, 2 Mobile Phones,
1 Drone, 1 DSLR, 3 iPads, 1
Bluetooth Speaker, 5 HDD
4 Kupyanskiy Anton Chief Engineer 2 Mobile Phones, 1 HDD
5 Morante Edward 2nd Engineer 1 Mobile Phone, 1 Camera,
1 Flash Drive
6 Camay Arvic 3rd Engineer 1 Laptop, 1 HDD, 3 Mobile
Phones
7 Cahigus Elmer Bosun 2 Mobile phones, 1 Camera
8 Alano Harris Able Seaman 1 Laptop, 1 HDD, 2 Mobile
Phones
9 Abul Khair Motorman 1 Mobile Phone, 1 Camera,
1 iPod
10 Nunez Santy Chief Cook 1 Laptop, 2 HDD, 1 Mobile
Phone, 3 Flash Drive

9. Date and signature by master, authorized agent or officer

 CREW LIST
(IMO FAL Form 5)

✓ Arrival Departure
1.1 Name of ship 1.2 IMO number 1.3 Call sign 1.4 Voyage number
M.T PACIFIC GRAY 9613616 3FVO6 01/09
2. Port of arrival/departure 3. Date of arrival/departure 4. Flag State of ship 5. Last port of call
Maptaphut, Thailand January 01, 2019 PANAMA TBA
6. 7. Family name 8. Given 9. Rank or rating 10. 11. Date of 12. Place of 13. 14. Nature 15. Number 16. Issuing 17. Expiry date
No. names Nationality birth birth Gender of identity of identity State of of identity
document document identity document
document

1 Demyanosky Greg Master Russian 20/01/1970 USSR Male Passport 711111111 USSR 23/05/2022
2 Kosaruv Sergie Chief Officer Ukrainian 11/02/1976 Ukraine Male Passport EK222222 Ukraine 10/11/2026
3 Ramos John 2nd Officer Filipino 25/07/1993 Cebu City Male Passport EC3333333 Philippines 09/04/1921
Brian
4 Kupyanskiy Anton Chief Engineer Russian 18/09/1973 USSR Male Passport 714444444 USSR 27/03/2022
5 Morante Edward 2nd Engineer Filipino 01/05/1975 Dimiao, Male Passport EC55555555 Philippines 07/12/2022
Bohol
6 Camay Arvic 3rd Engineer Filipino 22/10/1990 Imus, Male Passport EC6666666 Philippines 18/06/2020
Cavite
7 Cahigus Elmer Bosun Filipino 15/01/1963 Baybay, Male Passport EC7777777 Philippines 19/03/2022
Leyte
8 Alano Harris Able Seaman Filipino 06/04/1993 Camiling, Male Passport EC8888888 Philippines 13/05/2021
Tarlac
9 Abul Khair Motorman Indian 03/10/1989 Mumbai, Male Passport AD999999 India 27/11/2027
India
10 Nunez Santy Chief Cook Filipino 03/05/1988 Baguio City Male Passport EC1010101 Philippines 04/03/2022
18. Date and signature by master, authorized agent or officer

*Disclaimer: I am using Microsoft Word 2016 if there is changes this is due to the out of date Microsoft word.