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ISPS 3

Form of Declaration of Security for Ship-Port Faci

lity Inte rfac e

Declaration of Security

Name ofShi p /M; l /lj{P /lf) ~J 'h1 ? 6-

Port of Registry h-:z::-63 ea.;zzn
IMO Number
Name of Port Facility
~=.;"'J'f .f"_
&gg--2-J'L--
,-r:p
This Declaration is valid from O2/I){) VJqfo until (!) 7 !lJOVt( ~for the following
activities:

Activity
Yes No
Loading/ Unloa ding/ Trans fer of Cargo
~ ;><
Loading/ Unloa ding/ Transfer of bunke rs & fresh water
)c
Receiving/ Landing spare s/ store s/ provis ions
~ ,Xi
Crew emba rkatio n/ disem barka tion
X ~
Vessel inspe ctions / surve ys/ atten dance by customs,
port officials, classification societies, agents, owne
rs
immig ration ,
?<J v--
Visitors to vessel
V /t'
Unde r the follow ing secur ity levels:
Security level of ship: @/
Security level of port facilit y: 6> f

RevO 07/18 ISPS 3

The port facility and the ship agree to the
following security mea sures and responslbl
accordance with their approved security plans litlM In
.

The affixing of the lnltlals of the

responsible person under these
columns indicates that the activity
will be done in accordance with the
relevant approved pla
Activity
Ensuring performance of all security duties
Communication between the ship and port
facility
Means of raising alarm agreed between
ship and
port facility
Ensuring that security communication
is readily
available between ship and port facility
Controlling access to port facility
Controlling access to the ship
Monitoring of port facility including berth
ing areas
and areas surrounding the ship
Mon itorin g of ship including berthing areas
and
areas surrounding the ship
Handling of cargo, ship stores

Handling unaccompanied baggage

Controlling embarkation of personnel
and their
effects
Mon itorin g restricted areas to ensure
that only
authorized persons have access

The signatories to this agreement certify

that security measures and arrangements
the ship and the port facility will be imple for both
mented in accordance with the provisions
in the respective approved plans. stipu lated

For and behalf of the ship For and behalf of the port facir
Signature of Signature of PFSO
Mastel7SSO
Name Name
ntle Title
Date /Tim e Date/Time

Revo 07/18 ISPS 3

I
 Contact details: (Ind icate contact telep
hone numbers or radio channels or freq
r:,
used) uencies to be

Port facility:

PFSO Name: Lo:r:s .f rN1.1uAN 12e ;{4/ Tz;STtt-W l

Tel. Nos:
cif 13 }J oJ/2 5r{f.
Radio Channels guarded: _ _ _ _
_ _ _ __

Ship:
Tel. Nos if any: f-J ?-0 ?-3--37-e;/O -?-, -1-J52_5 Jot '9- ~5-
Radio channels guarded: Ct i--/ t{
CSO:
Name:
Tel. Nos : -trrlU <ZllcJfo?-

Agents:
Name: Mre1--1EL /!-vo, vy~/-lt r1~ clb t./Au-- -
Tel. Nos: ---l- fi5 I 333J J955~ ~ r z5/J 9fl,t?- - :?~ 3~
7
Radio channels guarded:
----------

Original : Master Copy : Office

Rev o 01/1 8 ISPS 3

 ISPS 3

Form of Declaration of Security for Ship-Port Faci

lity Interface

Declaration of Security

Name of Ship /IJM-.D tl.11rvrf/O; b

Port of Registry .Lwe:12i:-11
IMO Number
Name of Port Facility ~ r+71J E1e.1-rzax.--
This Declaration is valid from
activities:
£ 1A)oIJ 2(') f 6 until cJ /Of t}q }f!J for the following

Activity
Yes No
Loading/ Unloading/ Transfer of Cargo
L-,/ "
Loading/ Unloading/ Transfer of bunkers & fresh
water v
Receiving/ Landing spares/ stores/ provisions
V
Crew embarkation/ disembarkation ~
Vessel inspections/ surveys/ attendance by custo
ms, immigration,
port officials, classification societies, agents, owne ~
rs
Visitors to vessel
~

Under the following security levels:

Security level of ship: c) f
Security level of port facility: ~ !
'

Revo 07/18 ISPS 3

r
The port facility and the ship agree to the
following securIty mea sures and respons,bnitle-s ln
accordance with their approved security plans
.

The affl,clng of the Initials of the

responsible person under these
columns Indicates that the activity
will be done in accordance with the
relevant approved plan .
Activity Ship Po aclltty
Ensuring performance of all security dutie
s
Communication between the ship and port
facility
Means of raising alarm agreed between
ship and
port facility
Ensuring that security communication
is readily
available between ship and port facility
Controlling access to port facility
Controlling access to the ship
Monitoring of port facility including berth
ing areas
and areas surrounding the ship
Monitoring of ship including berthing areas
and
areas surrounding the ship
Handling of cargo, ship stores

Handling unaccompanied baggage

Controlling embarkation of personnel
and their
effects
Mon itorin g restricted areas to ensure
that only
authorized persons have access

The signatories to this agreement certify

that security measures and arrangements
the ship and the port facility will be imple for both
mented in accordance with the provisions
in the respective approved plans. stipu lated

For and behalf of the ship

Signature of
Signature of PFSO
M r/SSO

Na me R_t -<3,-IVU) fJ NJ4.:I. L Na me

Title f2p... . Title
Date / Time C)I) / oJtJ . Date / Time

Rev o 01/18 ISPS 3

 Contact details: (Indicate contact telephone
numbers or radio channels or frequencies
used) lo be

Port facility:
PFSO Name:
Tel. Nos:

Radio Channels guarded: ____,C='--'M_--'-l.,6'__.'---= -- -- --

Ship:
Tel. Nos if any: j:8 ?07 -?3 ? 6/J.3?: -1- 5 ?,< ?Jr,C ?-?-~ 5
Radio channels guarded: U fl/} ()-I -/( .
CSO:
Name:
M •Stl-TM Y-4
Tel. Nos: +J 5.P ?32: I 39' CJ 9.

Agents:
Name: (1)$ Wut t-S 04R.l/J.$, co M1tT:s r,H-Z, -{!}/JGfllrGOrJ f)f-/ l/l/l7 1Yll- 1efr
Tel. Nos: - 1- - 26 ?-I 2°/ C/ Ct3 !
Radio channels guarded:
----------

Original : Master Copy : Office

Rev o 01/18 ISPS 3