(1) Reference number;
(2) Name of seaman; (3) Discharge Book number, or date and place of birth; (4) Name of ship in which last employed; (5) Address of seaman; (6) Name and relationship of next-of-kin, and address if different from seaman’s; (7) Rate of wages; (8) Date of commencement of employment on board; (9) If discharged, the reason for discharge; (10) Date and place of leaving the ship; (11) Signature of seaman on engagement; (12) Signature of seaman on discharge, or if not discharged, the reason for being left behind, if known; (13) Signature of the person before whom the seaman is discharged; (14) Certificates of Competency and/or Service held by seamen listed, including (a) Capacity in which employed; Number of Certificate of Competency; Description of Certificates of Competency and/or Service held including all Endorsements (e. g. restrictions; dangerous cargo endorsements).
