ANEXO 1-H

REGISTRO DE DATAS DE EMBARQUE/DESEMBARQUE

(Record of Embarkment and Disembarkment Dates)

__________________
VISTO
NOME/FUNÇÃO
(VISA / Name and function)

LOCAL:___________________________________________________________ DATA: _____/______________/______.

(City/Country) (Date) dd mm yyyy

EMPRESA/NAVIO: _____________________________________________________________________________________
(Ship Company/Vessel Name)

NOME DO AQUAVIÁRIO:________________________________________________________________________________
(Seafarer’s Name)

EMBARCAÇÃO DATA EMBARQUE DATA DESEMBARQUE FUNÇÃO PERÍODO DE EMBARQUE

(Vessel)
PORTO PORTO (Function) ANO(S) MÊS(ES) DIA(S)
(Embarkment Date/Port) (Disembarkment Date/Port) (Year(s) month(ties) day(s)

______________________________________________________________________
ASSINATURA
NOME DO REPRESENTANTE DA EMPRESA OU COMANDANTE DO NAVIO
(Signature)
(Shipping Company Representative or Ship Master Full Name)

- 1-H-8 - N13/2003