Regulations > Immigration Regulations, 2014 > Annexures > Annexure A: Forms

Immigration Act, 2002 (Act No. 13 of 2002)

Regulations

Immigration Regulations, 2014

Annexures

Annexure A: Forms

Form 39 (DHA-128)

(DHA-128) Form 39

Dept of Home Affairs Icon

LISTS OF PASSENGERS AND CREW, MEDICAL RETURN AND COASTAL ADVICE

[Section 7(1)(g) read with section 35(5)(a), (c) and (d); Regulation 34(9)]

LIST OF PASSENGERS

The person in charge of a conveyance entering or prior to entering a port of entry of the Republic shall, on demand, deliver to an immigration officer a list of all passengers on board that conveyance, which list shall contain the following information:

Name of conveyance: ........................................................................................................................................................................

Departing from: .......................................................................................................................................................................(place)

Arriving at: ..............................................................................................................................................................................(place)

Name and surname of person in charge of conveyance .......................................................................................................................

*Flight/Registration No.: ....................................................................................................................................................................

Date of entry: .....................................................................................................................................................................................

Particulars of all passengers on board classified according to their respective destinations (inbound):

Surname and initials	Passport/Travel document no	Nationality	Embarked at	Destination

I hereby certify that this list contains the particulars of all passengers on board my conveyance.

........................................................................... ................................................

Signature of person in charge of conveyance Date

List received by:

Name and surname of immigration officer .......................................................................................................................................

Appointment No: .............................................................................................................................................................................

Signature: ......................................................................................... Date: ......................................................................................

Place ................................................................................................................................................................................................

LIST OF CREW AND PERSONS CARRIED OTHER THAN PASSENGERS AND STOWAWAYS

The person in charge of a conveyance which enters any port must, on demand, deliver to the immigration officer a list of all the crew and all persons (other than passengers and stowaways) employed, carried or present on that conveyance.

Name of conveyance: ......................................................................................................................................................................

Port of entry (at country of departure): ............................................................................................................................................

Name(s) and surname of person in charge of conveyance:................................................................................................................

Date on which conveyance entered the Republic: ............................................................................................................................

Port of entry: ...................................................................................................................................................................................

Date of final departure from Republic: .............................................................................................................................................

Next port of call: ..............................................................................................................................................................................

Crew list:

List of other persons carried (other than passengers and stowaways):

I certify that this list contains the names of all crew and persons other than passengers and stowaways on board the conveyance.

................................................................................ .....................................................

Person in charge of conveyance Date

List received by:

Name and surname of immigration officer: ...........................................................................................................

Appointment No: ...................................................................

Signature: ................................................................................ Date: .........................................................

MEDICAL RETURN

Name of conveyance: ...............................................................................................................................................................................................................

Port of entry: ............................................................................................................................................................................................................................

Crew, passengers and all other persons on board conveyance who, during the voyage, have suffered or are suspected of suffering from a disease, whether infectious or otherwise:

Surname and initial(s)

Rank/Class

Nature of illness

Remarks

______________________________________________

____________________________

____________________________________

________________________________________

Details of any birth or death that occurred on board the conveyance between the present and previous port:

Name (mention father and mother's name in case of birth)

Rank/Class

Birth/Death

Date

Remarks

______________________________________________

_________________________

___________________________

__________________

_______________________________________

Certified by me .....................................................................................................................................(name and surname of medical officer/person in charge of the conveyance) at ..............................................................................................................................(port of entry) on the ........................day of .................................................................20..........

...........................................................................................................

Signature of *medical officer/person in charge of conveyance

*Delete which is not applicable

COASTAL ADVICE

(To be completed by immigration officer for conveyance destined for more than one port in the Republic)

TO: Immigration officer at ..................................................................................................... (next port of call in the Republic)

Name of conveyance: ........................................................................................................................................................................

Ship's File No: ...................................................................................................................................................................................

Number of illegal foreigners .............................. and reasons for their illegality: ........................................................................................................................................

....................................................................................................................................................................................................................................................................

Note: (Attach notice issued to the person in charge of ship, dependent on the reason of illegality).

Number of passengers in transit: ................................................................................................................................................................................................................

Number of persons for final disembarkation: .............................................................................................................................................................................................

Number of foreign crew: ............................................................................................................................................................................................................................

Number of crew members who are citizens or permanent residence holders: ............................................................................................................................................

Number of persons whose final departure must be certified: .....................................................................................................................................................................

Number of stowaways remaining on board declared by the master of the ship at last port of call: ...............................................................................................................

Remarks:

Dispatched from ..................................................................................................................................................................................................................(port of entry)

.................................................................... .................................................................... ....................................................................

Signature of immigration officer Appointment number Date

Surname and initial(s)

Nationality

Date of birth

Passport No.

Expiry date of passport