Declaration of Security Form

Name

Message

This Declaration os Security is valid from

Until

For the following Activities:

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 the Maritime Security Measures.

The affixing of the initials of the SSO or PFSO under these columns indicates that the activity will be done, in accordance with relevant approved plan, by

Activity

The Port Facility:

The Ship:

Ensuring the performance of all security duties

Monitoring restricted areas to ensure that only authorised personnel have access

Controlling access to port facility

Controlling access to the ship

Monitoring of 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 port facility

The signatories to this agreement certify that security measures and arrangements for both the port facility and the ship during the specified activities meet the provisions of the Maritime Security Measures that will be implemented in accordance with the provisions already stipulated in their approved plans or the specific arrangements agreed to and set out in the attached annex.

Date

Password P.F.S.O

Password M.S.S.O

Name and title of person who signed

Contact Details
(to be completed as appropriate)
(indicate the telephone numbers or the radio channels or frequencies to be used)

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Note: This Form is for use between a ship and a port facility. If the Declaration of Security is to cover two or more ships, or a port, this form should be appropriately modified.

SSUSI