ISPS Declaration of Security (DoS) Form

1. General Information

Port Facility Name

Port Facility Code

Ship Name

IMO Number

Date

Location/Berth

Time (From - To)

2. Security Levels

	Ship	Port Facility
Security Level
Contracting Government that set the Level (if not standard)

3. Reasons for DoS

4. Agreed Security Measures

Security Activity / Responsibility	Responsible Party (Ship or PFSP)
Monitoring Restricted Areas
Monitoring Access Points
Checking Identification Documents
Escort of Visitors
Other Measures

5. Contact Information

Ship Security Officer (SSO) Name

Port Facility Security Officer (PFSO) Name

SSO Contact

PFSO Contact

6. Approvals

Signature	Date/Time
Ship Security Officer
Port Facility Security Officer