Note:This form must be completed neatly and submitted in duplicates Sheet 1 of 1

THE MARITIME AND PORT AUTHORITY OF SINGAPORE

(DANGEROUS GOODS, PETROLEUM AND ADVANCE NOTICE OF ARRIVAL/LOADING AND
EXPLOSIVES) APPLICATION TO DISCHARGE/LOAD/TRANSIT
REGULATIONS, 1997
Name of Vessel: Voy No: Type: ETA: Last Port: Licensed DG/Explosive Lighter Nos.
(if applicable)
BTR:

NOTE: Please arrange in the order of discharing/loading/transiting

MPA Discharge/Load/Transit Port
S/No Quantity, Type of Packing & Correct Technical Net Wt. Container Storage Onboard/ IMO UN No. FP Group Location Date/Time Chemist
Name og Substance (Trade Names Shall Not Be Used) (kg) No. Cell Location Class (C) Remarks

Name of Person Signing DECLARATION UNDER SECTION 10 OF THE MPA ARC(CHAPTER 170A) Remarks
Designation We hereby declare that the information provided is correct and undertake to fufill and comply
with all the regulations in respect of the Carriage of Dangerous Goods, including those
Name & Address of *Owner/Agent
remaining on board, as specified in the MPA (Dangerous Goods, Petroleum and Explosives)
Regulations, 1997.
Tel No Date
Fax No *Delete as appropriate Signature of Owners/Agent/Master (With Firm Company's stamp)

GENERAL CONDITIONS:
1. Agents are to ensure that they correctly declare the quantity, type of 3. For loading DG, applications must be submitted at least 24 hours (working days) before date
packaging,technical name, IMO class, UN No. and flash point. of cargo being loaded.
2. For discharging DG, applications must be submitted at least 24 hours (working 4. To avoid delays in processing the application, agents are urged to provide correct and
days) before vessel's arrival in port. complete information.