Dissotichus catch/re-export document

OMB Control
No. 0648-0194
Expiration Date:
6/30/2016

DISSOSTICHUS CATCH DOCUMENT
Document Number
PRODUCTION SECTION
1. Issuing Authority of Document
Name

Address

2. Fishing Vessel Name

Tel:
Fax:

Home Port & Registration Number

3. Licence Number (if issued)

Type

Estimated
Weight to be
Landed (kg)

Call Sign

IMO/Lloyd’s Number
(if issued)

Fishing dates for catch under this document
4. From:
5. To:

6. Description of Fish (Landed/Transhipped)
Species

V 1.4
Flag State Confirmation Number

Area
Caught*

Verified
Weight
Landed (kg)

7. Description of Fish Sold
Net Weight Recipient name, address, telephone, fax and
signature.
Sold (kg)
Recipient Name:
Signature:
Address:

Tel:
Fax:
Species: TOP Dissostichus eleginoides, TOA Dissostichus mawsoni
Type: WHO Whole; HAG Headed and gutted; HAT Headed and tailed; FLT Fillet; HGT Headed, gutted, tailed; OTH Other (specify)
8. Landing/Transhipment Information: I certify that the above information is complete, true and correct. If any Dissostichus spp. was taken in
the Convention Area, I certify that it was taken in a manner which is consistent with CCAMLR conservation measures:
Master of Fishing Vessel or Authorised Representative
(print in block letters)

Signature and Date

Landing/Transhipment
Port and Country/Area

Date of
Landing/Transhipment

9. Certificate of Transhipments: I certify that the above information is complete, true and correct to the best of my knowledge.
Master of Receiving Vessel
Signature
Vessel Name
Call Sign
IMO/Lloyds Number
(if issued)

Transhipment within a Port Area: countersignature by Port Authority if appropriate.
Name
Authority

Signature

Seal (Stamp)

10. Certificate of Landing: I certify that the above information is complete, true and correct to the best of my knowledge.
Name
Authority
Signature
Address
Tel.
Port of Landing
Date of Landing

11. EXPORT SECTION
Description of Fish
Species
Product
Net Weight
Type

Seal (Stamp)

12. Exporter Declaration: I certify that the above information is complete, true and correct
to the best of my knowledge.
Name
Address
Signature
Export Licence
(if issued)

13. Export Government Authority Validation: I certify that the above information is
complete, true and correct to the best of my knowledge.
Name/Title

Signature

Date

Country of export
14. IMPORT SECTION
Name of Importer

Address

Point of Unlading:

City

Seal (Stamp)

Export reference number

State/Province

Country

* Report FAO Statistical Area/Subarea/Division where catch was taken and indicate whether the catch was taken on
the high seas or within an EEZ.

DISSOSTICHUS RE-EXPORT DOCUMENT
RE-EXPORT SECTION

V1.1

Re-exporting Country:

1. Description of Fish
Species

Type of Product

Net Weight
Exported (kg)

Dissostichus Catch Document
Number Attached

Species: TOP Dissostichus eleginoides, TOA Dissostichus mawsoni
Type: WHO Whole; HAG Headed and gutted; HAT Headed and tailed; FLT Fillet;
HGT Headed, gutted, tailed; OTH Other (specify)
2. Re-Exporter Certification: I certify that the above information is complete, true and correct to the best of
my knowledge and that the above product comes from product certified by the attached Dissostichus Catch
Document(s).
Name

Address

Signature

Date

Export Licence
(if issued)

3. Re-Export Government Authority Validation: I certify that the above information is complete, true, and
correct to the best of my knowledge.
Name/Title

Signature

4. IMPORT SECTION
Name of Importer

Point of Unlading:

Date

Seal (Stamp)

Address

City

State/Province

Country