Permohonan Sijil SoC - Jabatan Laut Malaysia
Permohonan Sijil SoC - Jabatan Laut Malaysia
Permohonan Sijil SoC - Jabatan Laut Malaysia
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JLM/ISPS/<strong>SoC</strong><br />
JABATAN LAUT MALAYSIA<br />
BORANG PERMOHONAN PERAKUAN KEPATUHAN<br />
STATEMENT OF COMPLIANCE (<strong>SoC</strong>)<br />
STATEMENT OF COMPLIANCE APPLICATION FORM<br />
Sila tandakan √ yang berkenaan<br />
Please tick √ where applicable<br />
<strong>Permohonan</strong> baru Pengendorsan Pembaharuan<br />
New Application Endorsement Renewal<br />
Kemaskini maklumat<br />
Infos update<br />
Gantian sijil<br />
Replacement<br />
A. BUTIR‐BUTIR PEGAWAI SEKURITI KAWASAN / KEMUDAHAN PELABUHAN<br />
MARITIME TRANSPORT SECURITY OFFICER (MTSO) / MARINE FACILITY SECURTITY OFFICER<br />
(MFSO) DETAILS<br />
1. Nama Penuh : ___________________________________________________________<br />
Full Name<br />
2. No. Kad Pengenalan : ___________________________________________________________<br />
I.C No<br />
3. Alamat : ___________________________________________________________<br />
Address<br />
___________________________________________________________<br />
4. No. Telefon : ___________________________________________________________<br />
Phone No<br />
5. No. Faks : ___________________________________________________________<br />
Fax no.<br />
6. Alamat Email : ___________________________________________________________<br />
Email Address<br />
7. Latihan MFSO : ____________________________________________( Tempat & Tarikh )<br />
MFSO Training ( Place & Date )<br />
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JLM/ISPS/<strong>SoC</strong><br />
B. BUTIR‐BUTIR KAWASAN PELABUHAN (MT) & KEMUDAHAN PELABUHAN (MF)<br />
MT& MF DETAILS<br />
8. Nama Pelabuhan : __________________________________________________________<br />
Name of Port<br />
9. Nama MF : __________________________________________________________<br />
Name of MF<br />
10. Lokasi ( Lat / Long) : ______________________________( mengikut wartaan titik koordinat)<br />
Location ( Lat / Long ) : ______________________________( as gazzetted co‐ordinates )<br />
: ______________________________<br />
: ______________________________<br />
: ______________________________<br />
: ______________________________<br />
11. Keluasan : ______________________________<br />
Area (Square kilometer<br />
or hectare)<br />
12. Jenis Kapal<br />
Ship Type<br />
Passenger ship<br />
Passenger high‐speed craft<br />
Cargo high speed craft<br />
Bulk Carrier<br />
Oil Tanker<br />
Chemical Tanker<br />
Gas Carrier<br />
Mobile Offshore Drilling Units<br />
Cargo Ships other than above<br />
13. Kekerapan : ____________________ / setahun<br />
Frequency<br />
/ year<br />
(ship visit per year)<br />
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JLM/ISPS/<strong>SoC</strong><br />
C. PERAKUAN<br />
ACKNOWLEDGEMENT<br />
Saya mengaku bahawa butir‐butir seperti yang dinyatakan di atas adalah benar dan bertanggungjawab<br />
ke atasnya.<br />
I hereby admit all the above details are true and liable to the matter<br />
__________________<br />
Tarikh<br />
Date<br />
_______________________<br />
Tandatangan Pemohon<br />
Signature<br />
Kembalikan borang permohonan yang<br />
telah dilengkapkan kepada :<br />
<strong>Jabatan</strong> <strong>Laut</strong> <strong>Malaysia</strong><br />
Ibu Pejabat <strong>Laut</strong>,<br />
Peti Surat 12, Jalan Limbungan<br />
42007, Pelabuhan Klang Selangor<br />
(U/p : En.Mohammad Hisham bin Ali)<br />
Bahagian Kawalan Industri<br />
Unit Penguatkuasaan Kod ISPS<br />
(emel : isps@marine.gov.my)<br />
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