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Model VII. (Verklaring ten behpeve van den (Engelsch.) gezagvoerder, van den reeder of van diens vertegenwoordiger.)

N°._

DECLARATION, mentioned under B of article 40 of the Royal Decree of 15 May 1933 (Staatsblad n°. 276), as to the sanitary

measures to which the ship,

named , its cargo and the

persons on board have been submitted in the harbour at the roadstead

The Burgomaster of ;

ha ving regard to what is appointed under B of article 40 of the Royal Decree of 15 May 1933 (Staatsblad n°. 276);

having seen the written report, dated

19_ , n°. , of , ;

hereby declares:

a. that the ship, named

sailing under the flag;

in the harbour

which arrived of

at the roadstead

on the day of 19 ;

captain : —■. ;

representative of the owner in this country: 1 ;

port of departure : .....;

intermediate ports : ;

next port of destination : ;

has been submitted to the following sanitary measures:

b. that the cargo of the ship mentioned under a has been submitted to the following sanitary measures:

c. that the persons on board the ship mentioned under a have been submitted to the following sanitary measures:

Delivered on the day of — 19—

at

The Burgomaster,

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