Maritime Security Declaration

1. Ship Information

Name of Ship

IMO Number

Flag State

Company

Security Officer Name & Title

2. Port Facility Information

Name of Port Facility

Location

Port Facility Code

Port Facility Security Officer

3. Security Levels

Ship Security Level	Port Facility Security Level	Level in Force During Interface

4. Security Measures to be Implemented

Details

5. Agreement on Security Measures

6. Other Additional Comments

7. Signatures

Name & Title (Ship Security Officer) Date

Name & Title (Port Facility Security Officer) Date