ISPS Code Declaration of Security (DoS) Form
Port Facility / Ship Name
IMO Number
Port / Location
Date
Time (UTC)
Berth/Anchorage
Security Levels
Port Facility Security Level
1
2
3
Ship Security Level
1
2
3
Details of Security Measures to be Implemented
Activity
Responsibility (Ship / Port Facility)
Monitoring restricted areas
Controlling access to ship/port facility
Screening of persons and luggage
Security patrols
Other measures
Contact Information of Persons Responsible
Ship Security Officer (SSO)
Contact Number
Port Facility Security Officer (PFSO)
Contact Number
Additional Security Measures (if any)
Declaration
Name (Ship)
Title
Signature
Date
Name (Port Facility)
Title
Signature
Date