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09/30/2014 1. Function of this document (Check one) DECLARATION (Complete items 1-17 and 20-26) ENTRY 19. Entry Number 20. Principal Name (Complete items 1-16 and 20-28; 19 if available) Importer No. Phone Address 3. Represented Locally By: Name Address 4. Vessel Name Phone 5. IMO No. 7. Last U.S. Departure Port 9. Foreign Port Arrived From 8. Last U.S. Departure Date 10. Voyage No. 14. Location (City and Country) and Sailing Date from that Country 17. CERTIFICATION OF MASTER 11.

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