Schedule
FORM A
(Regulation 15)
FORM OF THE INTERNATIONAL SHIP
SECURITY CERTIFICATE
INTERNATIONAL SHIP SECURITY CERTIFICATE
(Official seal) (State)
Certificate Number ........................................
Issued under the provisions of the
INTERNATIONAL CODE FOR THE
SECURITY OF SHIPS AND OF PORT FACILITIES
(ISPS CODE)
under the authority of the Government of
_____________________________________________________________________________
(name of State)
by __________________________________________________________________________
(person(s) or organization authorized)
Name of ship....................................................................................................
Distinctive number of letters .................................................................................
Port of registry .................................................................................................
Type of ship ....................................................................................................
Gross tonnage ..................................................................................................
IMONumber....................................................................................................
Name and address of the Company .........................................................................
THIS IS TO CERTIFY:
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1. that the security system and any associated security equipment of the ship has been verified in accordance with section 19.1 of part A of the ISPS Code;
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2. that the verification showed that the security system and any associated security equipment of the ship is in all respects satisfactory and that the ship complies with the applicable requirements of chapter XI-2 of the Convention and Part A of the ISPS Code;
-
3. that the ship is provided with an approved ship security plan.
-
Date of initial/renewal verification on which this Certificate is based ........./........../.........
(Day/month/year)
This Certificate is valid until ............./.........../.......... Subject to verifications in accordance with section 19.1.1 of Part A of the ISPS Code.
Issued at ...........................................................................................................
(Place of issue of certificate)
Date of issue .............................. .....................................................................
(Signature of the duly authorized
official issuing the Certificate)
(Seal or stamp of issuing authority, as appropriate)
---------------------------------------------------------------------------------------
(Overleaf) Endorsement for immediate verification
THIS IS TO CERTIFY that at an intermediate verification required by section 19.1.1 of Part A of the ISPS Code the ship was found to comply with the relevant provisions of chapter XI-2 of the Convention and Part A of the ISPS Code.
Intermediate verification Signed: .......................................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
(Seal or stamp of the authority, as appropriate)
Endorsement for additional verifications
Additional verification Signed: .......................................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
(Seal or stamp of the authority, as appropriate)
Additional verification Signed: .............................................
(Signature of authorized official)
Place: ................................................
Date: .................................................
(Seal or stamp of the authority, as appropriate)
Additional verification Signed: ...............................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
(Seal or stamp of the authority, as appropriate)
THIS IS TO CERTIFY that at an additional verification required by section 19.3.7.2 of Part A of the ISPS Code the ship was found to comply with the relevant provisions of chapter XI-2 of the Convention and Part A of the ISPS Code.
Signed: ...............................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
(Seal or stamp of the authority, as appropriate)
Endorsement to extend the certificate if valid for less than 5 years where section A/19.3.3 of the ISPS Code applies
The ship complies with the relevant provisions of part A of the ISPS Code, and the Certificate shall, in accordance with section 19.3.3 of Part A of the ISPS Code, be accepted as valid until ...............................................
Signed: ................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
(Seal or stamp of the authority, as appropriate)
Endorsement where the renewal verification has been completed and section A/19.3.4 of the ISPS Code applies
The ship complies with the relevant provisions of part A of the ISPS Code, and the Certificate shall, in accordance with section 19.3.3 of part A of the ISPS Code, be accepted as valid until..................................................
Signed: ...............................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
(Seal or stamp of the authority, as appropriate)
Endorsement to extend the validity of the certificate until reaching the port of verification where section A/19.3.5 of the ISPS Code applies or for a period of grace where section A/19.3.6 of the ISPS Code applies
The Certificate shall, in accordance with section 19.3.5/19.3.6* of part A of the ISPS Code, be accepted as valid until..............................................
Signed: ...............................................
(Signature of authorized official)
Place: ..................................................
Date: ...................................................
(Seal or stamp of the authority, as appropriate)
* Delete as appropriate
Endorsement for advancement of expiry date where section A/19.3.7.1 of the ISPS Code applies
In accordance with section 19.3.7.1 of Part A of the ISPS Code, the new expiry date is..............................................................................
Signed: ...............................................
(Signature of authorized official)
Place: ................................................
Date: .................................................
(Seal or stamp of the authority, as appropriate)
FORM B
(Regulation 19)
FORM OF THE INTERIM INTERNATIONAL SHIP
SECURITY CERTIFICATE
INTERIM INTERNATIONAL SHIP SECURITY CERTIFICATE
(Official seal) (State)
Certificate Number ........................................
Issued under the provisions of the
INTERNATIONAL CODE FOR THE
SECURITY OF SHIPS AND OF PORT FACILITIES
(ISPS CODE)
under the authority of the Government of
_____________________________________________________________________________
(name of State)
by __________________________________________________________________________
(person(s) or organization authorized)
Nameofship.............................................................................................................
Distinctive number of letters..........................................................................................
Port of registry..................................................................................................
Type of ship.....................................................................................................
Gross tonnage...................................................................................................
IMONumber....................................................................................................
Name and address of the Company...........................................................................
Is this a subsequent, consecutive Interim Certificate? Yes/No
If Yes, date of issue of initial Interim Certificate............................................................
THIS IS TO CERTIFY THAT the requirements of section A/19.4.2 of the ISPS Code have been complied with.
This Certificate is issued pursuant to section A/19.4 of the ISPS Code.
This Certificate is valid until..................................................................................
Issued at..........................................................................................................
(Place of issue of the Certificate)
(Date of issue) ....................... ...........................................................................
(Signature of the duly authorized official
issuing the Certificate)
(Seal or stamp of the authority, as appropriate)
FORM C
(Regulation 35)
FORM OF A STATEMENT OF COMPLIANCE
OF A PORT FACILITY
STATEMENT OF COMPLIANCE OF A PORT FACILITY
(Official seal) (State)
Statement Number ........................................
Issued under the provisions of Part B of the
INTERNATIONAL CODE FOR THE
SECURITY OF SHIPS AND OF PORT FACILITIES
(ISPS CODE)
The Government of
_____________________________________________________________________________
(name of State)
Name of the port facility..............................................................................................
Address of the port facility............................................................................................
THIS IS TO CERTIFY That the compliance of this port facility with the provisions of chapter XI-2 of the Convention and Part A of the International Code of the Security of Ships and of Port Facilities (ISPS Code) has been verified and that this port facility operates in accordance with the approved port facility security plan. This plan has been approved for the following specify the types of operations, types of ship or activities or other relevant information (delete as appropriate):
Passenger ship
Passenger high-speed craft
Cargo high-speed craft
Bulk carrier
Oil tanker
Chemical tanker
Gas carrier
Mobile offshore drilling units
Cargo ships other than those referred to above
This Statement of Compliance is valid until ............................................................... subject
to verifications (as indicated overleaf)
Issued at..................................................................................................................
(place of issue of the statement)
Date of issue............................................................................................................
(Signature of the duly authorized
official issuing the document)
(Seal or stamp of the authority, as appropriate)
Endorsement for verifications
The Government of insert name of the State has established that the validity of this Statement of Compliance is subject to insert relevant details of the verifications (e.g. mandatory annual or unscheduled).
THIS IS TO CERTIFY that, during a verification carried out in accordance with paragraph B/16.6.62.4 of the ISPS Code, the port facility was found to comply with the relevant provisions of chapter X1-2 of the Convention and Part A of the ISPS Code.
1st VERIFICATION Signed: ...........................................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
2nd VERIFICATION Signed: ........................................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
3rd VERIFICATION Signed: .........................................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
4th VERIFICATION Signed: ........................................................................
(Signature of authorized official)
Place: .................................................
Date: ..................................................
FORM D
(Regulation 47)
Form Of A Declaration Of Security Between A Ship And A Port Facility
DECLARATION OF SECURITY
| Name of ship: | |
| Port of registry: | |
| IMO Number: | |
| Name of port facility: | |
This Declaration of Security is valid from ..................................................................... until .................................. for the following activities:
...........................................................................................................
(list the activities with relevant details)
under the following security levels |
| Security level(s) for the ship: | |
| Security level(s) for the port facility: | |
| The port facility and ship agree to the following security measures and responsibilities to ensure compliance with the requirements of Part A of the International Code for the Security of Ships and of Port Facilities. |
| The affixing of the initials of the SSO or PFSO under these columns indicates that the activity will be done, in accordance with the relevant approved plan, by |
| Activity | The port facility: | The ship: |
| Ensuring the performance of all security duties | |
| Monitoring restricted areas to ensurethat only authorized personnel have access | |
| Controlling access to the port facility | |
| Controlling access to the ship | |
| Monitoring of the port facility, including berthing areas and areas surrounding the ship | |
| Monitoring of the ship, including berthing areas and areas surrounding the ship | |
| Handling of cargo | |
| Delivery of ship's stores | |
| Handling unaccompanied baggage | |
| Controlling the embarkation of persons and their effects | |
| Ensuring that security communication is readily available between the ship and the port facility | |
The signatories to this agreement certify that security measures and arrangements for both the port facility Part A of the Code that will be implemented in accordance with the provisions already stipulated in their approved plan or the specific arrangements agreed to and set out in the attached annex.
Dated at ........................................................... on the..................................... |
| Signed for and on behalf of |
| the port facility | : the ship: |
(Signature of port facility security (Signature of master or security
officer) officer) |
| Name and title of person who signed |
| Name: | Name: |
| Title: | Title: |
Contact details
(to be completed as appropriate)
(indicate the telephone numbers or the radio channels
or frequencies to be used) |
| for the port facility: | for the ship: |
| Port facility | Master |
| Port facility security officer | Ship security officer |
| Company |
| Company security officer |
FORM E
(Regulation 47)
Form Of A Declaration Of Security Between A Ship And Another Ship
DECLARATION OF SECURITY
| Ship-A | Ship-B |
| Name of ship: | | |
| Port of registry: | | |
| IMO Number: | | |
| Name of port facility: | | |
This Declaration of Security is valid from .................................................. until .................................. For the following activities:
..................................................................................................................
(list the activities with relevant details)
under the following security levels |
| Security level(s) for the ship A: | |
| Security level(s) for the ship B: | |
| Ship-A and Ship-B agree to the following security measures and responsibilities to ensure compliance with the requirements of Part A of the International Code for the Security of Ships and of Port Facilities. |
| The affixing of the initials of the SSO,s under these columns indicates that the activity will be done, in accordance with the relevant approved plan, by |
| Activity | Ship-A: | Ship- B: |
| Ensuring the performance of all security duties | |
| Monitoring restricted areas to ensure that only authorized personnel have access | |
| Controlling access to Ship–A | |
| Controlling access to Ship-B | |
| Monitoring of Ship-A, including areas surrounding Ship | |
| Monitoring of ship-B, including areas surrounding the ship | |
| Handling of cargo | |
| Delivery of ship's stores | |
| Handling unaccompanied baggage | |
| Controlling the embarkation of persons and their effects | |
Ensuring that security communication
is readily available between the ships | |
This signatories to this agreement certify that security measures and arrangements for both ships Part A of the Code that will be implemented in accordance with the provisions already stipulated in their approved plan or the specific arrangements agreed to and set out in the attached annex.
Dated at ...................................................... on the ........................................... |
| Signed for and on behalf of |
| Ship-A: | Ship-B: |
(Signature of master or ship security officer)
| Name and title of person who signed |
| Name: | Name: |
| Title: | Title: |
Contact details
(to be completed as appropriate)
(indicate the telephone numbers or the radio channels
or frequencies to be used) |
| for ship-A: | for ship-B: |
| Master | Master |
| Ship security officer | Ship security officer |
| Company | Company |
| Company security officer | Company security officer |