REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF FINANCE
BUREAU OF CUSTOMS

_________________________

Oath of Master covering list of Officers on Coastwise Vessel

A complete list of crew aboard the __________________________________________________________________

Sailing from the port of ___________________ on the ____________ day of ______________ 20 _______________
For the Port of ____________________________.

No Name Age Capacity Nationality Place of Residence Nearest relative

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District of __________________________)
Port of ____________________________) s.s

I, ________________________________ Master of ___________________________________________do

solemnly swear or affirm that the foregoing is a full and complete list of crew on board said vessel on its present voyage
and that all statement contained therein are true and correct to the best of my knowledge and belief.

____________________________
(Master)
License No. _____________
Issued by _____________
Issued on _____________

SUBSCRIBED AND SWORN to before me this ______________________ at the place as indicated above.

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Empowered to Administer Oath under the provisions of Section 1147 of the
Administrative Code