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Please complete using BLOCK CAPITALSPlease complete electronically TO BE COMPLETED BY ALL VISITORS TO BAS STATIONS OR RESEARCH SHIPS VISITING SHIPCRUISE NUMBERORVISITING BASEPROJECT NAMEBAS POINT OF CONTACTPERSONAL DETAILS SURNAME (as on passport) FIRST NAME (as on passport)M/F & TitlePERMANENT HOME ADDRESS Telephone No (home)Email(mobile) (work)(personal)(work)Date of birth Nationality Passport numberDate of issue Please also complete food allergens/requirements formPlace

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