| Name and IMO number of receiving ship |
| Port |
| Date of commencement of delivery |
| Name, address, and telephone number of marine fuel oil supplier |
| Product name(s) |
| Quantity (metric tons) |
| Density at 15°C (kg/m3)* |
| Sulphur content (% m/m)† |
| A declaration signed and certified by the fuel oil supplier's representative that the fuel oil supplied is in conformity with regulation 14(1) or (4)(a) and regulation 18(1) of this Annex. |
|