IMO CREW’S EFFECTS DECLARATION

(IMO FA L Form 4)

Page Numbe

r

1.1 Name of ship

Malmo

1.2 IMO number

8116738

1.3 Call sign

4LVR

1.4 Voyage number
112432

2. Flag State of ship

Tanzania

3.

No.

4.

Family name, given names

5.

Rank or rating

6. Effects ineligible for relief from
customs duties and taxes or subject to
prohibitions or restrictions

*

7. Signature

1

Damian Rolewski

Master

[Wine - 5l, Whiskey -1l]

2

Krzysztof Ignaczak

1

st

mate

-

3

John Brown

2

nd

mate

-

4

Jon Snow

3

rd

mate

-

5

Robb Stark

Bosun

-

6

Tytus Bomba

Cook

[Cigaretes – 10, Beer 2l]

7

Michał Głuś

O/S

[Cigaretes–5,Vodka 0,5l]

8

Kamil Zdun

O/S

[Vodka – 1l]

9

Radosław Rumian

O/S

-

10

Bogusław Łęcina

Cadet

-

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

10.05.2014
Rolewski Damian

*

e.g., wines, spirits, cigarettes, tobacco, etc.