#502 Westcourt Place 251 Goyeau Street Windsor, Ontario N9A 6V2

Windsor Port Authority Vessel Inward / Outward Report

Phone:  519-258-5741 E Mail: wpa@portwindsor.com

Name of Vessel : Country of Registry : Name of Master : Last Port of Call : Name of Owner : Next Port of Call : Name of Agent : Berthed at: : ARRIVAL DATE :  DEPARTURE DATE : ARRIVAL TIME : DEPARTURE TIME : COUNTRY OF DESTINATION OF CARGO LOADED AT WINDSOR : COUNTRY OF ORIGIN OF CARGO UNLOADED AT WINDSOR : OFFICE USE CUSTOMER VESSEL CODE  DOCK  IMP. CODE EXP.  CODE # CARGO COMMODITY CARGO TO BE BROKEN DOWN INTO COMMODITITES WITH RESPECTIVE TONNAGES FOR EACH NO. OF UNITS WEIGHT IN METRIC TONNES  (# 2,200) OFFICE USE ONLY IN OUT CODE   RATE FEES   1 . . . . . . . . 2 . . . . . . . . 3 . . . . . . . . 4 . . . . . . . . NUMBER OF PASSENGERS: Cargo and Harbour dues are payable in accordance with Bylaw covering cargo and harbour dues in Windsor Harbour in respect of every vessel thirty feet and over in length that enters Windsor Harbour other than vessels proceeding through the harbour without stopping to move or tie up. Cargo and harbour dues are a charge against the vessel. I HEREBY CERTIFY that the above is true and correct statement Name (signature) I am the   Master      Owner       OR Agent               DATE: