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2014-08-015 Rev 0 ACR I-Card Certification

BI certification for alien certificate of registration identity card

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This document may be reproduced and is NOT FOR SALE

IMMIGRATION PORT CLEARANCE
The MV/MT/FB/MY _________________________________ is hereby granted clearance to depart from the
Port of ____________________________________ to its next port of call, having mustered out all its crew and
passengers (if any) and found their travel documents to be in order, and in accordance with Philippine Immigration
Laws and Regulations, particulars of which are as follows:
Next Port of Call
Date of Departure [DD-MMM-YYYY e.g. 01 JAN 1990]

Time of Departure [e.g.1525H]

H
Nationalities of Crew Members:

Number

TOTAL
Number

Number

JOINING (SIGN ON)

REPATRIATED (SIGN OFF)

STOWAWAY

WORKAWAY

LEFT BEHIND

JUMPED SHIP

HOSPTALIZED

NEEDS MEDICAL ATTENTION

OTHERS, please specify:

PASSENGERS ON BOARD

DIED ON SHIP

PASSENGERS WHO EMBARKED AT PORT

NATIONALITIES OF EMBARKING PASSENGERS

Number

TOTAL
REMARKS:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
DATE
: _____________________
ATTESTED : _____________________

_____________________________
COMMISSIONER
Bureau of Immigration

_______________________________
MASTER/CAPTAIN
(Signature over Printed Name)

____________________________
DEPARTURE CONTROL OFFICER
(Signature over Printed Name)

DOCUMENTS SUBMITTED:
EMBARKING CREW LIST
EMBARKING PASSENGER MANIFEST
DEPARTURE CREW LIST
DEPARTING PASSENGER MANIFEST
OTHERS, please specify:
______________________________
______________________________
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