General Declaration (Outward/inward) - Canada

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GENERAL DECLARATION
DÉCLARATION GÉNÉRALE
(Outward/Inward)
(Sortie/Entrée)
Operator
Exploitant
Flight No.
Marks of nationality and registration
Date
N° de vol
Marques de nationalité et d'immatriculation
Departure from (place)
Arrival at (place)
Départ de (localité)
Arrivée à (localité)
Flight routing - Itinéraire de vol
("place" column always to list origin, every en-route stop, and destination)
(inscrivez dans la colonne «localité» l'origine, chaque escale et la destination)
*
**
Place
Total number of crew
Number of passengers on this stage
*
**
Localité
Effectif de l'équipage
Nombre de passagers sur ce tronçon
Departure place - Lieu de départ :
Embarking
Embarqués
Through on same flight
En transit même vol
Arrival place - Lieu d'arrivée :
Disembarking
Débarqués
Through on same flight
En transit même vol
Declaration of health*
Déclaration de santé*
Do not use this area
N'inscrivez rien ici
Persons on board with illnesses other than airsickness
Cas de maladie (à l'exclusion du mal de l'air ou des
or the effects of accidents (including persons with
accidents) constatés à bord ou débarqués au cours du
symptoms or signs of illness such as rash, fever, chills,
voyage, y compris les personnes présentant des
diarrhoea) as well as those cases of illness
symptômes ou signes tels que éruption, fièvre,
disembarked during the flight.
frissons, diarrhée.
Any other conditions on board which may lead to the
Toute autre circonstance à bord de nature à provoquer
spread of disease.
la propagation d'une maladie.
Details of each disinsecting or sanitary treatment
Renseignements détaillés sur chaque désinsectisa-
(place, date, time, method) during the flight. If no
tion ou autre opération sanitaire (lieu, date, heure,
disinsecting has been carried out during the flight give
méthode) effectuée au cours du vol. S'il n'y a pas eu
details or most recent disinsecting.
de désinsectisation en cours de vol, donnez des
précisions sur la désinsectisation la plus récente.
Signed, if required
Signature, s'il y a lieu
Crew member concerned
Membre d'équipage intéressé
I declare that all statements and particulars contained in this general declaration and
Je, soussigné, déclare que toutes les indications et tous les renseignements contenus dans la
in any supplementary forms required to be presented with this general declaration are
présente déclaration générale ainsi que dans tous les formulaires supplémentaires qui
complete, exact, and true to the best of my knowledge, and that all through
doivent accompagner cette déclaration générale donnent, à ma connaissance, un exposé
passengers will continue/have continued on the flight.
complet, sincère et véritable de la situation. Je déclare en outre que tous les passagers en
transit poursuivront (ont poursuivi) le voyage sur le même vol.
Signature
Authorized agent or pilot-in-command - Agent agréé ou pilote commandant de bord
*
To be completed only when required by the State.
*
Ne remplissez que si l'État l'exige.
Not to be completed when passenger manifests are presented and to be
Ne remplissez pas lorsque des manifestes de passagers sont présentés, et ne
**
**
completed only when required by the State.
remplissez que si l'État l'exige.
Dans ce formulaire, toutes les expressions désignant des personnes visent à la fois les hommes et les femmes.
AG1 (04)
Printed in Canada - Imprimé au Canada

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