A. VESSEL NAME:
B. COUNTRY OF REGISTRY:
C. REGISTERED OWNER:
D. OPERATOR NAME:
E. NAME OF CLASSIFICATION SOCIETY :
F. INTERNATIONAL RADIO CALL-SIGN:
G. SEND A COPY OF
INTERNATIONAL SHIP SECURITY CERTIFICATE (ISSC) ...
or CANADIAN VESSEL SECURITY CERTIFICATE
H. IN REFERENCE TO G.
1 Date of issuance:
2.Date of expiry:
3.Name of Issuing body:
I. VESSEL'S INTERNATIONAL MARITIME ORGANIZATION NUMBER, IF IT IS A SOLAS
SHIP:
J. CONFIRMATION THAT VESSEL HAS AN APPROVED VESSEL SECURITY PLAN : YEs    No
K. CURRENT MARSEC LEVEL: 
L. STATEMENT OF WHEN ITS LAST 10 DECLARATIONS OF SECURITY WERE COMPLETED:
1.                     6.
2.                     7. 
3.                     8. 
4.                     9.
5.                    10.
M. DETAILS OF ANY SECURITY THREATS TO THE VESSEL DURING THE LAST TEN CALLS AT MARINE FACILITIES:
N. A STATEMENT AS TO WHETHER THE VESSEL CONSENTS TO TRACKING BY THE CANADIAN GOVERNMENT:
O. DETAILS OF ANY DEFICIENCIES IN ITS SECURITY EQUIPMENT AND SYSTEMS, INCLUDING THE COMMUNICATION SYSTEMS AND THE WAY IN WHICH THE MASTER OF THE VESSEL INTENDS TO RECTIFY THEM:
P. IF APPLICABLE, THE NAME OF IT'S AGENT AND THEIR 24-HOUR TELEPHONE AND FACSIMILE NUMBERS.
Q. IF APPLICABLE, THE NAME OF ITS CHARTERER:
R. VESSEL'S POSITION AND TIME AT WHICH IT REACHED THAT POSITION:
S. VESSEL'S COURSE AND SPEED:
T. VESSEL'S DESTINATION AND ESTIMATED TIME OF ARRIVAL AT ITS DESTINATION:
U. NAME OF A CONTACT PERSON AT THE MARINE FACILITY THAT IT WILL VISIT AND THEIR 24-HOUR 
TELEPHONE AND FACSIMILE NUMBERS:
V. THE FOLLOWING INFORMATION FOR EACH OF THE LAST TEN MARINE FACILITIES 
VISITED:
1. THE RECEIVING FACILITY:
2. THE MARINE FACILITY VISITED:
3. THE CITY AND COUNTRY:
4. THE DATE AND TIME OF ARRIVAL AND:
5. THE DATE AND TIME OF DEPARTURE:

EXAMPLE:
1. ALCAN TERMINAL
2. BERTH 2
3. PORT ALFRED, CANADA
4. 28-08-04 1200 UTC
5. 29-08-04 2400 UTC

W. GENERAL DESCRIPTION OF THE CARGO, INCLUDING CARGO AMOUNT; AND 
X. IF APPLICABLE, THE PRESENCE AND DESCRIPTION OF ANY DANGEROUS SUBSTANCES OR DEVICES ON BOARD.