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中华人民共和国出入境检验检疫
船舶免予卫生控制措施证书/船舶卫生控制措施证书 申请书
APPLICATION FORM FOR SHIP SANITATION CONTROL EXEMPTION CERTIFICATE/ SHIP SANITATION CONTROL CERTIFICATE Entry-Exit Inspection and Quarantine of the P.R.of China
编号No._____________
现申请你局于________年____月____日对本船舶实施卫生监督，并根据检查结果采取卫生控制措施，签发《船舶免予卫生控制措施证书/船舶卫生控制证书》。
I hereby apply for a sanitation inspection over my ship on the date of _______________ and on the basis of the result, applying control measures and iuing SHIP SANITATION CONTROL EXEMPTION CERTIFICATE/SHIP SANITATION CONTROL CERTIFICATE.船名 国籍
Name of Ship______________________ Nationality__________________________ 总吨位 净吨位 货舱数
Gro Tons___________ Net Tons_____________ Number of Hatches___________ 船上载有货物种类及数量
Description and Quantity of Cargo on Board_________________________________
预定货物卸空日期
Date Expected for Completing Discharge____________________________________
船长签字 日期
Signature of Captain_______________________ Date_______________________
