APPLICATION FOR FREE PRATIQUE
Name of vessel __________________________
Call Sign _____________________________
Registration / IMO No. _______________________
Line __________________________
Nationality___________________________
Type of vessel _______________________
E.T.A. ______________________ (hours)
on __________________________ Anchorage
No. of crew_____________
No. of passenger _______________________
Is there a ship surgeon on board? Yes / No
Did your vessel visit any ports in Our Country on or after "Date" ? Yes / No
If Yes, please list out all ports of call since the last 30 days
If No, please list out all ports of call for the last 30 days:
Name of Port and Country
Date of departure
Name of Port and Country
Date of departure
(please use supplementary sheet if the above spaces are not enough)
Has any case of infectious diseases occurred on board during the past 30 days? Yes / No
Has the total number of ill passengers during the past 30 days been greater than normal / expected? Yes / No
Is there any ill person on board now? Yes / No
Has any person died on board during the past 30 days? Yes / No
Have any stowaways been found on board? Yes / No
Is there any sick animal or pet on board? Yes / No
Has any sanitary measure (e.g. quarantine, isolation, disinfection or decontamination) been applied on board? Yes / No
Date, port and country of issue of Ship Sanitation Certificate under the IHR(2005): _______________________
Did any port health authority make any recommendations/comments on the Certificate? If yes, please state particulars:
I certify that the above statements are true. A copy of Maritime Declaration of Health (D.H. 168) and Ship Sanitation Certificate together with crew and passenger lists will be forwarded for inspection within 24 hours of arrival.
Name of applicant (in block letters)
Signature
Agent / Owner
Fax. No. Date
Tel. No.
FREE PRATIQUE
FOR OFFICIAL USE ONLY
To: Applicant (Ref No. )
Free Pratique is hereby granted to the above-named vessel subject to the following conditions:
(a) the Maritime Declaration of Health, Ship Sanitation Certificate, and crew list and passenger list from the Master should be delivered to this office within 24 hours after the ship’s arrival.
(b) if there is any change in health conditions on board, this pratique will automatically become invalid and the vessel should proceed to the Quarantine Anchorages for Port Health clearance.
(c) this Free Pratique is valid up to 24 hours after the expected time of arrival. It will automatically expire after this period.
Free Pratique is not granted to the above-named vessel.
Remarks:
Date:
D.H. 1418J (Rev. Apr 2011)
for Chief Port Health Officer
