Annex 1 to Klaipeda State Seaport
Shipping Rules
BOUNDARIES OF THE SEAPORT HARBOUR WATERS
1. Inner harbour waters of the Seaport are limited:
1.1. In the South – with a line between the points (WGS 84):
55° 37' 56,59'' N
21° 08' 04,26'' E;
55° 38' 01,69'' N
21° 09' 28,20'' E
1.2. in the West – along the line of the eastern coast of the Curonian Spit, except 30 meter
water zone along the coast;
1.3. in the East – by the coast line;
1.4. in the North – by the line connecting the edges of the Seaport breakwaters.
2. External raid of the Seaport is limited with lines between the points (WGS 84):
55° 48' 00'' N
20° 45' 00'' E;
55° 48' 00'' N
20°50' 00'' E;
55° 48' 00'' N
21° 03' 58'' E;
55° 39' 00'' N
21° 06' 01'' E;
55° 40' 28'' N
20° 50' 00'' E;
55° 41' 17'' N
20° 45' 00'' E.
3. The Navigation Channel is marked with navigation signs according to lateral system and
alignments from buoy No. 1 in the Sea to the Southern part of the Seaport inner harbour waters.
THE SEAPORT PLAN
______________
Annex 2 to Klaipeda State Seaport
Shipping Rules
THE LIST OF SERVICES OF THE STATE ENTERPRISE KLAIPEDA STATE SEAPORT
AUTHORITY AND SEAPORT USERS TO BE INFORMED ABOUT THE VESSEL
DEPARTURE
Ro
w
No.
Name
Tel. No.
Fax
E-mail
1
2
3
4
5
1.
SE Klaipeda State Seaport
Authority
UTB channel;
call sign;
Cell phone
6
1.1. Director General
(8 46) 49 97 99 (8 46) 49 97 77
info@port.lt
1.2. Harbour Master
(8 46) 49 96 88 (8 46) 49 96 66
ukt@port.lt
1.3. Vessel Traffic Service
(8 46) 49 96 91
(8 46) 49 97 29
(8 46) 31 08 40
let@port.lt
9, 16;
Klaipėda radio-5
Dispatcher of the Seaport
1.4.
Control Department
(8 46) 49 97 04
(8 46) 49 96 35 (8 46) 49 96 46
(8 46) 38 22 56
operator@port.lt
10;
Klaipėda radio-12
8 612 54 144
10;
Klaipėda radio-32
8 616 51 527
Senior inspector of the
1.5. Seaport Control
Department
(8 46) 49 96 41 (8 46) 49 96 71
ups@port.lt
Specialist on dangerous
1.6. cargoes of the Seaport
Control Department
(8 46) 49 96 23 (8 46) 49 96 46
dgoods@port.lt
(8 46) 46 96 02 (8 46) 46 96 00
msa@msa.lt
2.
The Lithuanian Maritime
Safety Administration
2.1. Director
2.2.
Head of the Seaport
Control Department
(8 46) 46 96 63 (8 46) 46 96 55
linas.kasparavicius@
msa.lt
2.3.
Head of the Commercial
Maritime Department
(8 46) 46 96 59 (8 46) 46 96 55
povilas.pauparas@
msa.lt
Head of the
2.4. Hydrographical and
Navigation Equipment
Department
(8 46) 46 97 02 (8 46) 46 97 01
viktoras.liulys@
msa.lt
The Department for
Supervision of the
2.5.
Activity of Economic
Agents
(8 46) 46 98 85 (8 46) 46 96 00 tadas.skimelis@msa.lt
2
2.6.
3.
Shipping Inspector on
Duty
„Klaipėdos nafta“, AB
3.1. Dispatcher
4.
Kndisp@oil.lt
6, 9;
Klaipėdos nafta
(8 46) 39 10 86 (8 46) 39 10 83
dispatcher@terminal.l
t
9; Cargo terminal
8 615 59 972
vp.disp@klasco.lt
14;
Klaipėda radio-2
8 614 26 971
disp.tjp@klasco.lt
15;
Klaipėda radio-8
8 687 88 741
„Klaipėdos jūrų krovinių
kompanija“, AB
5.1. Dispatcher
Dispatcher of the
International ferry
5.2.
terminal
6.
„Litectus III“, UAB
7.
Klaipeda Ship repair
Company
7.1. Harbour Master
7.2. Castle Port
8.
(8 46) 39 16 95
(8 46) 39 16 72
(8 46) 39 17 75
„Krovinių terminalas“,
UAB
4.1. Dispatcher
5.
8 616 59 791
(8 46) 39 94 82 (8 46) 39 95 25
(8 46) 39 96 05 (8 46) 39 96 32
(8 655) 25 606
(8 46) 21 49
25
info@ports.lt
9; Klaipeda ship
repair
8 698 85 297
vilius@ports.lt
8 650 20 450
dispecer@bega.lt
6, 9; Bega
8 614 57 708
info@ckt.lt
9;
8 698 39 986
ops@smelte.lt
25;
Klaipėda radio-31
8 615 89 618
(8 46) 49 63 55 (8 46) 49 63 50
ref@smelte.lt
25;
Klaipėda radio-31
8 698 85 611
(8 46) 30 44 01 (8 46) 30 44 10
dispatcher@bkt.lt
6, 9; Bulk cargo
terminal
(8 46) 49 09 76 (8 46) 49 09 99
(8 46) 49 09 99
„Bega“, UAB KJKK
8.1. Dispatcher
(8 46) 39 55 33 (8 46) 34 10 34
9.
Central Klaipeda terminal,
(8 46) 31 33 96 (8 46) 31 31 36
UAB
10.
„Klaipėdos Smeltė“,
LKAB
10.1.
Dispatcher of the
Container Terminal
Dispatcher of Frozen
10.2.
Cargoes
11.
darius.favus@
gmail.com
(8 46) 49 63 44 (8 46) 49 63 45
Bulk Cargo terminal,
UAB
11.1. Dispatcher
3
8 682 32 797
12.
„Mabre LPC“, UAB
(8 46) 41 16 93 (8 46) 41 16 92
krova@mabrelpc.lt
9; Mabre
8 686 07 579
8 612 42 113
8 615 58 579
(8 46) 48 36 59 (8 46) 48 36 90
dispecerine@wsy.lt
6, 9; West load
8 698 85 469
(8 46) 49 08 60 (8 46) 49 08 61
arunas.sarkauskas@
miterminalas.lt
9; Malku Bay
terminal
8 618 70 585
(8 46) 30 09 58 (8 46) 30 09 59
ktdispecerine@
terminalas.lt
6, 9; Container
terminal
8 686 20 223
(8 46) 35 52 18 (8 46) 35 52 18
dispecerine@
terminalas.lt
6, 9;
8 698 53 112
info@towage.lt
6, 9;
Tak-1, Tak-2, Tak3, Tak-4,Tak-5,
Tak-6, Tak-9
8 614 68 388
Western Shipyard, AB,
13. Western Baltija
Shipbuilding, UAB
13.1. Dispatcher
14.
Malku Bay Terminal,
UAB
14.1. Dispatcher
15.
Klaipeda Container
Terminal, UAB
Dispatcher of the
15.1.
Container Terminal
15.2.
Dispatcher of Ro-Ro and
GC Terminal
16. Vessel towing companies
16.1. „Towmar Baltic“, UAB
(8 46) 30 34 27 (8 46) 30 34 28
„Klasco towage
assistance“ Branch of
16.2.
„Klaipėdos jūrų krovinių
kompanija“, AB
(8 46) 39 95 85 (8 46) 39 91 19
kta@klasco.lt
9, 14;
Klaipėda radio-2
8 612 12 207
16.3. AB Western Shipyard
(8 46) 48 37 64 (8 46) 48 36 12
marketing@wsy.lt;
andrius.kontenis@
wsy.lt
6, 9; West load
8 612 24 504
8 698 22 860
(8 46) 39 12 57
(8 46) 39 12 59
(8 46) 39 12 58
mrcc@mil.lt
16, 67;
Klaipėda rescue
17.
Sea Rescue Coordination
Centre
18.
Integrated maritime
Control System (IJSS)
19.
Seaport posts of Klaipeda
territorial customs
19.1. Breakwater Seaport Post
19.2. Malku Bay Seaport Post
69,
Maritime control
(8 46) 39 94 77 (8 46) 39 94 77
(8 46) 39 35
(8 46 39 35 15
molas.pamaina@
cust.lt
lu90.pamaina@cust.lt
4
15
19.3. Castle Seaport Post
(8 46) 34 23
95
(8 46) 34 23 95
pilis.pamaina@
cust.lt
Coast Security Unit of the
(8 46) 39 78 50 (8 46) 39 78 72
20. State Boarder Guard
Service
20.1. Seaport outpost
(8 46) 46 63 65
(8 46) 46 63 65
(8 46) 39 71 91
20.2. Kopgalis outpost
(8 46) 39 11 69
Quarantine Post of
21. Klaipeda Public Health
centre
22.
73; Impulsas-3
(8 46) 39 91 08 (8 46) 39 91 08
mkp@
klaipedosvsc.sam.lt
State Food and Veterinary
Service
22.1.
Breakwater boarder
veterinary post
(8 46) 39 94 49 (8 46) 39 94 39
molopvp@vet.lt
22.2.
Castle boarder veterinary
post
(8 46) 34 53 18
(8 46) 34 53 18
(8 46) 34 27 87
piliespvp@vet.lt
22.3.
Malku Bay Boarder
Veterinary post
(8 46) 35 50 44 (8 46) 35 50 42
malkupvp@vet.lt
______________
Annex 3 to Klaipeda State Seaport
Shipping Rules
KLAIPEDA STATE SEAPORT AUTHORITY
NOTIFICATION
INFORMATION TO BE NOTED BEFORE ENTRY INTO THE KLAIPEDA SEAPORT
1. Vessel name ...................................................................................................................................................... Call sign..................
Where appropriate IMO number of the ship ........................................................................................................................................
2. Flag State .................................................................................................................................................Quay No ..........................
3. Estimated time of arrival (ETA).......................................................................................................................................................
4. Estimated time of departure (ETD) ..................................................................................................................................................
5. Previous port of call ........................................................................................................................................................................
6. Next port of call ..............................................................................................................................................................................
7 Last port and date when ship-generated waste was delivered
. ............................................................................................................................................................................................................
8. The amount of waste delivered into port reception facilities?
All
Some
None
Tic proper box
9. Type and amount of waste and residues to be delivered and/or remaining on board.
–If delivering all waste, complete second column as appropriate
–If delivering some or no waste, complete all columns
Type
1.
Waste to be
removed,
m3
Maximum dedicated
storage capacity,
m3
Amount of waste
Port at which
retained on
remaining waste
board,
will be delivered
m3
Estimated amount of
waste to be generated
between notification and
next port of call, m3
Waste oils
Sludge
Bilge water
Engine oil/lubricants
Others (Specify)
2.
Garbage
Food waste
Plastic
Oily rags
Others (Specify)
3.
4.
5.
Cargo - associated waste
Specify, may be estimates
Cargo residues
Specify, may be estimates
Sewage/grey water
Notes:
1. This information may be used for Port State Control and other inspection purposes.
2. Member States will determine which bodies will receive copies of this notification
3. This form is to be completed unless the ship is covered by an exemption in accordance with article 9 of Directive 2000/59/EC of the
European Parliament and of the Council on port reception facilities for ship-generated waste and cargo residues.
I hereby confirm that the above details are accurate and correct and there is sufficient dedicated on board capacity to store all waste
generated between notification and the next port at which waste will be delivered.
Shipmaster
Date
Time
Signature
..........................
..........................
..........................
..........................
Agent
Date
Time
Signature
Telephone, fax
Mobile telephone
.......................
.......................
.......................
.......................
.......................
.......................
Agent stamp
______________
Annex 4 to Klaipeda State Seaport
Shipping Rules
SHIP PRE-ARRIVAL SECURITY INFORMATION FORM
FOR ALL SHIPS PRIOR TO ENTRY INTO THE PORT OF AN EU MEMBER STATE
(SOLAS REGULATION XI-2/9 AND ARTICLE 6.1 OF REGULATION (EC) No. 725/2004)
TO BE SUBMITTED TO THE COMPETENT AUTHORITY FOR MARITIME SECURITY OF
THE PORT OF ARRIVAL
Particulars of the ship and contact details
IMO number
Port of registry
Type of ship
Gross Tonnage
Name of
Company
Port of arrival
Vessel name
Flag State
Call Sign
Inmarsat call numbers (if any)
CSO name &
24 hour contact details
Port facility of arrival (if known)
Port and port facility information
Expected date and time of arrival of
the ship in port (ETA)
Primary purpose of call
Information required by SOLAS regulation 9.2.1 of Chapter XI-2
Does the ship have a valid
International Ship Security
Certificate (ISSC)?
YES
Does the ship have an
approved SSP on board?
YES
NO – why not?
ISSC
NO
Security Level at which
the ship is currently
operating?
Issued by (name of
Expiry date
Administration or
RSO)
(dd/mm/yyyy)
Security
Level 1
Security
Level 2
Security
Level 3
Location of ship at the time this
report is made
List the last 10 calls at port facilities in chronological order (most recent call first):
No
Date from
Date to
(dd/mm/yyyy)
(dd/mm/yyyy)
Port
Country
UNLO CODE
(if any)
Port facility
Security
Level
1
SL =
2
SL =
3
SL =
4
SL =
5
SL =
6
SL =
7
SL =
8
SL =
9
SL =
10
SL =
Did the ship take any special or additional security measures, beyond those in the approved SSP?
If the answer is YES, indicate below the special or additional security measures taken by the ship.
No
(as above)
Special or additional security measures taken by the ship
YES
NO
1
2
3
4
5
6
7
8
9
10
List the ship-to-ship activities, in chronological order (most recent first), which were carried out during the last 10 calls
at port facilities listed above. Expand table below or continue on separate page if necessary – insert total number of
ship-to-ship activities:
Were the ship security procedures specified in the approved SSP maintained during each of these
ship-to-ship activities?
If NO, provide details of the security measures applied in lieu in the final column below.
No
Date from
Date to
(dd/mm/yyyy)
(dd/mm/yyyy)
Location or
Longitude and
Latitude
Ship-to-ship activity
YES
NO
Security measures applied in lieu
1
2
3
4
5
6
7
8
9
10
General description of the cargo aboard the
ship
Is the ship carrying any dangerous substances as cargo
covered by any of Classes 1, 2.1, 2.3, 3, 4.1, 5.1, 6.1,
6.2, 7 or 8 of the IMDG Code?
YES
NO
If YES, confirm Dangerous Goods Manifest
(or relevant extract) is attached
Confirm a copy of ship’s crew list is attached
YES
Confirm a copy of the ship’s passenger list
is attached
YES
Other security related information
Is there any security-related matter
you wish to report?
YES
Provide details:
NO
Agent of ship at intended port of arrival
Name, surname:
Contact details (Phone No):
Identification of person providing the information
Title or Position (delete as appropriate):
Master / SSO / CSO / Ship’s agent (as above)
Name, surname:
Signature:
Date, time, place of completion of report
_______________
Annex 5 to Klaipeda State Seaport
Shipping Rules
PORT OF KLAIPEDA
SHIP'S DECLARATION
Ship's name
Call Sign
Ship's Flag
Ref. No
Ship's Certificate
(port, date, No)
IMO-No
Stevedoring Company (s) .....................................................
Port Authority
No
Date and time of Declaration Home Port
Voyage No
Shipping Agent (name, address, Phone, fax )
Customer No
Shipping Line (Licence No and date of expiry)
Flow of one-type cargo (title of the flow and the operator)
Ship's Owner / Charterer
Liner / Tramp
Service
Ship's Type
ARRIVAL
BT
Length
Width Overall (m)
Overall (m)
Actual Draught (m)
No of
crew
CUSTOMS
DOCUMENTS
Aft:
Customs Declaration No:
Cargo
Declaration
Passenger
List
GT
NRT
NRT
Summer Draught
(m)
Date and Time of arrival
Berth:
DW (T)
Hull:
Date and Time of Customs Clearance:
Crew List
Ship's Store
Declaration
Customs
Declaration
Port of origin of cargo
Last port
Country
Intermediate Ports (in chronological sequence)
Type of cargo (Text)
Code
Quantity of cargo handled in the Port of
Klaipeda
Number of units
empty
loaded
Gross Weight (T),
Volume (m3)
Passengers
Maritime Declaration of
Health
Cargo Handling
Operation commenced
..................................
Purpose of arrival
Shifting
from Quay No
from Quay No
from Quay No
from Quay No
date:
date:
date:
date:
DEPARTURE
No of crew
Fwd
CUSTOMS
Customs Declaration No.:
DOCUMENTS
Cargo
Declaration
Passenger
List
time:
time:
time:
time:
Aft:
to Quay No
to Quay No
to Quay No
to Quay No
Date and Time of
departure
date:
date:
date:
date:
time:
time:
time:
time:
Quay:
Hull:
Date and Time of Customs Clearance:
Crew List
Ship's Store
Declaration
Customs
Declaration
Port of destination
Next port
Country
Intermediate Ports (in chronological sequence)
Type of cargo (Text)
Code
Quantity of cargo handled in the Port of
Klaipeda
Number of units
empty
loaded
Gross Weight (T),
Volume (m3)
Passengers
Maritime Declaration of
Health
Cargo Handling
Operation completed
..................................
........................................
........................................
Departure:
PS watch keeper
Notes: No stowaways, guns, cartridges and drugs on board
Customer Official in Charge (Name and Signature)
Master's, Agent's or Officer's Name, Date and Signature
______________
Annex 6 to Klaipeda State
Seaport Shipping Rules
KLAIPEDA STATE SEAPORT AUTHORITY
ORDER FOR WASTE REMOVAL
Please collect waste from vessel:
1. Vessel name .................................................................................................................................................................... Call sign................
Where appropriate IMO number of the ship ......................................................................................................................................................
2. Flag State ................................................................................................................................................................. Quay No.......................
3. Full power h.p .................................................................................................................... Ship's pumping capacity in m3/h.......
4. Crew number.................... Number of passengers .........................................................................................................................................
5. Last port of call, date .....................................................................................................................................................................................
6. Time of arrival (TA) ......................................................................................................................................................................................
7. Estimated time of departure (ETD) ...............................................................................................................................................................
8. Collection to commence date/time. ...............................................................................................................................................................
9. Type and amount of waste and residues to be removed:
Type
1.
2.
3.
4.
5.
Waste to be
removed, m3
Maximum
dedicated storage
capacity,
m3
Estimated amount of waste
Amount of
Port at which
to be generated between
waste retained
remaining waste notification and next port of
on board,
will be delivered
call,
m3
m3
Waste oils
Sludge
Bilge water
Engine oil / lubricants
Others (Specify)
Garbage
Food waste
Plastic
Oily rags
Others (Specify)
Others (Specify)
Cargo - associated waste Specify,
may be estimates
Cargo residues /
Specify, may be estimates
Sewage / grey water
Notes:
This information may be used for Port State Control and other inspection purposes.
Customs seal
Agent
Date
Time
Signature
Telephone, fax
Mobile telephone
. .............................................................................
. .............................................................................
. .............................................................................
. .............................................................................
. .............................................................................
. .............................................................................
______________
Annex 7 to Klaipeda State
Seaport Shipping Rules
DANGEROUS GOODS MANIFEST
(As required by SOLAS 74, chapter VII, regulations 4.5 and 7-2.2, MARPOL 73/78, Annex III, regulation 4.3
and chapter 5.4, paragraph 5.4.3.1 of the IMDG Code)
Page Number
Ship's name
Voyage No
IMO No
Flag State
Booking / Marks & Numbers Number Proper
Reference Container Id. No (s) and kind Shipping
Number
Vehicle Reg. No (s) of
Name
packages
Master
Place and date
Signature of the Master
Call sign
Port of loading
Class
UN Packing
No Group
Port of discharge
Subsidiary Flash point Marine Mass (kg)
Risk (s)
(°C c.c)
pollutant Gross / Net
Shipping Agent
Place and date
Signature of the Agent
______________
EmS
Stowage
position on
board
Annex 8 to Klaipeda State
Seaport Shipping Rules
MULTIMODAL DANGEROUS CARGO FORM
This form may be used as a dangerous goods declaration as it meets the requirements of
SOLAS 74, chapter VII, regulation 5: MARPOL 73/78, Annex III, regulation 4, and section 9 of
General introduction to the IMDG code.
1. Shipper / consignor / sender
6. Consignee
8. This shipment is in
within the limitation
prescribed for: (delete
non applicable)
PASSENGER AND
CARGO
CARGO AIRCRAFT AIRCRAFT ONLY
10. Vessel voyage No 11. Port / place of
and date
loading
12. Port / place of
13. Destination
discharge
14. Shipping marks * Number and kind of
packages; description of goods
15. Container
identification
No/vehicle
registration No
2. Transport document number
3. page 1 of 4. Shipper's reference
pages
5. Freight forwarder's reference
7. Carrier (to be completed by the carrier)
SHIPPER'S DECLARATION
I hereby declare that the contents of this consignment
are fully and accurately described below by the
proper shipping name, and are classified, packaged,
marked and labelled/placarded and are in all respects
in proper condition for transport according to the
applicable international and national government
regulation.
9. Additional handling information
Gross mass (kg)
Net mass
Cube. m (m3)
16. Seal number(s) 17.
18. Tare 19. Total gross (including
Container/vehicle mass (kg) tare) (kg)
size & type
CONTAINER / VEHICLE
PACKING DOCUMENT
21. RECEIVING ORGANIZATION RECEIPT
Hereby declare that the goods
prescribed above have been packed /
loaded into the container / vehicle
identified above in accordance with
the applicable provision.**
MUST BE COMPLETED AND
SIGNED FOR ALL CONTAINER /
VEHICLE LOADS BY PERSON
RESPONSIBLE FOR PACKING /
LOADING.
Received the above number of packages/containers/trailers
in apparent good under good condition, unless stated hereon:
RECEIVING ORGANIZATION REMARKS:
Carrier`s name
Vehicle reg. No
Signature and date
20. Name of company
22. Name of company (of shipper
preparing this note)
Name/state of declarant
Name/status of declarant
Place and date
Place and date
Signature of declarant
Driver's signature
Signature of declarant
7 forma * DANGEROUS CARGO
You must specify proper shipping name, hazard class, UN No., packaging group (where
assigned), marine pollutant and observe the mandatory requirements under applicable national and
international governmental regulations. For purposes of the IMDG Code see paragraph 9.3
** For the purpose of the IMDG Code paragraph 12.3.7 or 17.7.7.
______________
Annex 9 to Klaipeda State
Seaport Shipping Rules
SHIP'S INTERIM DECLARATION
PORT OF KLAIPĖDA
Ship's name
Ship's Certificate (port, date, No)
Call Sign
Ship's Flag
Stevedoring Company (s) ------------------------------IMO-No
Date and time of Declaration
Home Port
Shipping Agent (name, address, phone, fax )
Shipping Line (Licence No and date of expiry)
Ship's Owner / Charterer
Liner /
Summer BT
GT
Width
TrampShip's Type Length Overall (m)
Draught
NRT
Overall (m)
Service
(m)
Actual Draught (m)
ARRIVAL
Ref. No
Port Authority
No
Voyage No
Customer No
Ref. No
Ref. No
DW(T)
No of crew Fwd
Aft:
CUSTOMS
Customs Declaration No
Cargo
Passenger
Crew List
DOCUMENTS Declaration List
Date and Time of arrival
Quay:
Hull:
Date and Time of Customs Clearance:
Ship's Store Customs
Maritime Declaration
Dec
Declaration of Health
Port of origin of cargo
Country
Last port of call
Intermediate Ports (in chronological sequence)
Type of cargo (Text)
Shifting
Code
from Quay No (hull)
from Quay No (hull)
from Quay No (hull)
from Quay No (hull)
Quantity of cargo handled in the
Port of Klaipeda
Number of units
Gross Weight
(T), Volume
empty
loaded
(m3)
date:
date:
date:
date:
time:
time:
time:
time:
Comments:
Customer Official in Charge (Name and Signature)
Cargo Handling
Operation
commenced:
...................................
Passengers ...................................
Arrived with cargo
completely to be
discharged
partly discharged
In ballast or empty
repair
from Quay No (hull)
from Quay No (hull)
from Quay No (hull)
from Quay No (hull)
date: time:
date: time:
date: time:
date: time:
NSS watch keeper
Master (Name and Surname, Date and Signature)
________
Annex 10 to Klaipeda State
Seaport Shipping Rules
CERTIFICATE FOR REPAIR WORKS IN PROGRESS IN THE VESSEL
Vessel name
IMO No.
Quay No.
Repair commencement date
Repair completion date
Name of the repair company
No. and validity period of license of
the repair company
Agent:
______________________________________________________________________________
(position, name, surname, signature, date, seal)
Confirmation of the representative of the repair company that repair works are in progress in the
vessel:
(position, name, surname, signature, date, seal)
________