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保全聲明

DECLARATION OF SECURITY
船名：Name of Ship  
登記港：Port of Registry  
IMO 編號：IMO Number  
港口設施名稱：Name of Port Facility  
本「保全聲明」之有效期自… … … … … …至… … … … … … …，涉及下列活動：

This Declaration of Security is valid from ........ until ......, for the following activities:

（活動清單，包括細節）

(list the activities with relevant details)

所處保全等級：
under the following security levels:

船舶保全等級：
Security level(s) for the ship:

 　

港口設施保全等級：
Security level(s) for the portfacility:

 　
港口設施和船舶同意以下保全措施和責任，以確保符合「國際船舶和港口設施保全章程」A 部分之要求。
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.

船舶保全員或港口設施保全員在本欄之簽名表示該活動將由其所代表之方面根據經認可之相關計畫完成。
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

活動：
Activity:

港口設施：
The port facility

船舶:
The ship

確保履行所有保全職責Ensuring the performance of all security duties

 　 　

監視限制區域確保只有經認可人員才能進入
Monitoring restricted areas to ensure that only authorized personnel have access

 　 　

對進入港口設施之控制
Controlling access to the port facility

 　 　

對進入船舶之控制
Controlling access to the ship

 　 　

監視港口設施，包括靠泊區域和船舶周圍水域
Monitoring of the port facility, including berthing areas and areas surrounding the ship

 　 　

監視船舶，包括靠泊區域和船舶周圍水域
Monitoring of the ship, including berthing areas and areas surrounding the ship

 　 　

貨物裝卸
Handling of cargo

 　 　

船舶物料交付
Delivery of ships stores

 　 　

非隨身行李裝卸
Handling unaccompanied baggage

 　 　

控制人員及其物品上船
Controlling the embarkation of persons and their effects

 　 　

確保船舶和港口之間之通信聯繫隨時可用
Ensuring that security communication is readily available between the ship and port facility

 　 　
本協定之簽名人證明在具體活動中港口設施和船舶之保全措施和安排符合第XI-2 章和本章程A 部分之規定，並將根據其經認可計畫之規定或所同意之列於附件中之具體安排來實施。
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 chapter XI-2 and Part A of 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.

簽署日期………………………………..地點……………………………………….
Dated at .............………………………...on the…………………………… ..............

代表簽名
Signed for and on behalf of

港口設施:
the port facility:

船舶:
the ship:
（港口設施保全員簽名） 　　　　　　　　　　　　　　　　　　　　　　（船長或船舶保全員簽名）
(Signature of Port Facility Security Officer) 　　　　　　　　　　　　　　　　　　(Signature of Master or Ship Security Officer)

簽名人姓名和職務Name and title of person who signed

姓名：
Name:

姓名：
Name:

職務：
Title :

職務：
Title :

聯繫細節Contact Details
（視情填寫）
(to be completed as appropriate)
（寫明電話號碼或無線電頻道或所用頻率）
(indicate the telephone numbers or the radio channels or frequencies to be used)

港口設施方：
for the port facility:

船舶方：
for the ship:
港口設施 Port Facility 　　　　　　　　　 　　　　　　　　船長Master

港口設施保全員Port Facility Security Officer　　　　　　　　　船舶保全員Ship Security Office r


公司Company

公司保全員Company Security Officer
最後更新日期：109-06-08
瀏覽人次：7067
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