Appendix

United Kingdom

SHIP PRE-ARRIVAL SECURITY INFORMATION FORM FOR ALL SHIPS PRIOR TO ENTRY INTO THE PORT OF AN EU MEMBER STATE

(1974 International Convention for the Safety of Life at Sea (SOLAS) Regulation 9 of Chapter XI-2 and Article 6(3) of Regulation (EC) No 725/2004)

Particulars of the ship and contact details
IMO number						Name of ship
Port of registry						Flag State
Type of ship						Call sign
Gross tonnage						Inmarsat call numbers (if available)
Name of company and company identification number						CSO name and 24 hour contact details
Port of arrival						Port facility of arrival (if known)
Port and port facility information
Expected date and time of arrival of the ship in port (ETA)
Primary purpose of call
Information required by SOLAS Regulation 9.2.1 of Chapter XI-2
Does the ship have a valid International Ship Security Certificate (ISSC)?			YES	ISSC		NO — why not?				Issued by (name of Administration or RSO)		Expiry date (dd/mm/yyyy)
Does the ship have an approved SSP on board?			YES	NO	Security level at which the ship is currently operating?				Security Level 1		Security Level 2	Security Level 3
Location of ship at the time this report is made
List the last 10 calls at port facilities in chronological order (most recent call first):
No	Date from (dd/mm/yyyy)	Date to (dd/mm/yyyy)		Port		Country		UN/LOCODE (if available)			Port facility		Security level
1													SL =
2													SL =
3													SL =
4													SL =
5													SL =
6													SL =
7													SL =
8													SL =
9													SL =
10													SL =
Did the ship take any special or additional security measures, beyond those in the approved SSP? If the answer is YES, indicate below the special or additional security measures taken by the ship.													YES	NO
No (as above)	Special or additional security measures taken by the ship
1
2
3
4
5
6
7
8
9
10
List the ship-to-ship activities, in chronological order (most recent first), which were carried out during the last 10 calls at port facilities listed above. Expand table below or continue on separate page if necessary — insert total number of ship-to-ship activities:
Were the ship security procedures specified in the approved SSP maintained during each of these ship-to-ship activities? If NO, provide details of the security measures applied in lieu in the final column below.													YES	NO
No	Date from (dd/mm/yyyy)	Date to (dd/mm/yyyy)		Location or longitude and latitude			Ship-to-ship activity				Security measures applied in lieu
1
2
3
4
5
6
7
8
9
10
General description of the cargo aboard the ship
Is the ship carrying any dangerous substances as cargo covered by any of Classes 1, 2.1, 2.3, 3, 4.1, 5.1, 6.1, 6.2, 7 or 8 of the IMDG Code?							YES	NO	If YES, confirm Dangerous Goods Manifest (or relevant extract) is attached
Confirm a copy of the ship’s crew list is attached							YES	Confirm a copy of the ship’s passenger list is attached						YES
Other security-related information
Is there any security-related matter you wish to report?				YES	Provide details:									NO
Agent of ship at intended port of arrival
Name:					Contact details (Tel. No):
Identification of person providing the information
Title or Position (delete as appropriate): Master/SSO/CSO/Ship’s agent (as above)					Name:				Signature:
Date/time/place of completion of report