1 Particulars of the ship and contact details 1.1 IMO Number
1, 21.2 Name of ship
1, 21.3 Port of registry
1, 21.4 Flag State
1, 21.6 Call Sign
1.7 Inmarsat call numbers
31.8 Gross Tonnage
11.9 Name of Company
1, 21.10 Name and 24-hour contact details of the Company Security Officer
42 Port and port facility information 2.1 Port of arrival and port facility where the ship is to berth, if known
2.2 Expected date and time of arrival of the ship in port (
paragraph B/4.39.3 of the
ISPS Code )
2.3 Primary purpose of call
3 Information required by SOLAS regulation XI-2/9.2.1 3.1 The ship is provided (
SOLAS regulation 9.2.1.1 ) with a valid:
- International Ship Security Certificate
□Yes □No
- Interim International Ship Security Certificate □Yes □No
3.1.1 The certificate indicated in 3.1 has been issued by
enter name of the Contracting
Government 1, 2or the Recognized Security Organization 1, 2> and which expires on
enter
date of expiry 1>.
3.1.2 If the ship is not provided with a valid International Ship Security Certificate or a valid
Interim International Ship Security Certificate, explain why?
3.1.2.1 Does the ship have an approved ship security plan on board? □Yes □No
3.2 Current security level (
SOLAS regulation XI-2/9.2.1.2 ): □
3.2.1 Location of the ship at the time the report is made (
paragraph B/4.39.2 of the ISPS Code )
3.3 List the last ten calls, in chronological order with the most recent call first, at port
facilities at which the ship conducted ship/port interface
5 together with the security level
at which the ship operated (
SOLAS regulation XI-2/9.2.1.3 ):
| Date | | |
No. | From6 | To6 | Port, Country, Port Facility and UNCLODE3 | Security level |
3.3.1 Did the ship, during the period specified 3.3, take any special or additional security
measures, beyond those specified in the approved ship security plan? □Yes □No
3.3.2 If the answer to 3.3.1 is YES, for each of such occasions please indicate the special or
additional security measures which were taken by the ship (
SOLAS
regulation XI-2/9.2.1.4 ):
| Date | | |
No. | From6 | To6 | Port, Country, Port Facility and UNCLODE3 | Special or additional security measures |
3.4 List the ship-to-ship activities
7, in chronological order with the most recent ship-to-ship
activity first, which have been carried out during the period specified in 3.3:
□ Not applicable
| Date | | |
No. | From6 | To6 | Location or Latitude and Longitude | Ship-to-ship activity |
3.4.1 Have the ship security procedures, specified in the approved ship security plan, been
maintained during each of the ship-to-ship activities specified in 3.4 (
SOLAS
regulation XI-2/9.2.1.5 )? □Yes □No
3.4.2 If the answer to 3.4.1 is NO, identify the ship-to-ship activities for which the ship security
procedures were not maintained and indicate, for each, the security measures which were
applied in lieu:
| Date | | |
No. | From6 | To6 | Security measures applied | Ship-to-ship activity |
3.5 Provide a general description of cargo aboard the ship (
SOLAS regulation XI-2/9.2.1.6
and paragraph B/4.39.5 of the ISPS Code ):
3.5.1 Is the ship carrying any dangerous substances
8 as cargo? □Yes □No
3.5.2 If the answer to 3.5.1 is YES, provide details or attach a copy of the Dangerous Goods
Manifest (IMO FAL Form 7)
3.6 A copy of the ship.s Crew List (IMO FAL Form 5) is attached □
(
SOLAS regulation XI-2/9.2.1.6 and paragraph B/4.39.4 of the ISPS Code )
3.7 A copy of the ship.s Passenger List (IMO FAL Form 6) is attached □
(
SOLAS regulation XI-2/9.2.1.6 and paragraph B/4.39.6 of the ISPS Code )
4 Other security-related information 4.1 Is there any security-related matter you wish to report? □Yes □No
4.1.1 If the answer to 4.1 is YES, provide details
95 Agent of the ship at the intended port of arrival 5.1 Name and contact details (telephone number) of the agent of the ship at the intended port
of arrival:
6 Identification of the person providing the information 6.1 Name:
6.2 Title or position
10:
6.3 Signature:
This report is dated at
enter place > on
enter time and date >.