AGENCY SHIPPING, CHARTERING AND FORWARDER
CV. ATHENA LAUTAN SAMUDERA
JL B Raya No. 11 RT. 005/ RW. 003 Kel. Rawabadak Utara Kac. Koja
Provinsi DKI Jakarta, Indonesia. Contact : +6281804900824 / +6285242336217
VESSEL NAME : MT. HD GOLD PORT : MUARA BERAU, SAMARINDA
VOY : 03/2024 DATE : MARCH 14TH,2024
Please submit to us to the original of statutory certificates and vessel's documents for Harbor master
and Immigration granting purpose as follow :
Purpouse : PKKA (Entry foreign Vessel Permit )
No. Ship Certificate Arrival Departure Remark
1 ITC
2 Registry Certificate
3 Class Certificate
4 ISSC
5 IOPP
6 CSO
7 SSO
8 CREW LIST
9 SHIP PARTICULAR
10 APPOINTMEN
Next port
Kindly acknowledge receipt of the above document by affixing your signature in this letter and return them
to vessel before sailing
Received by Boarding Agent Received by Master (Return back before sailing)
KARYADI * PIC of Boarding Agent :
Agent : CV ATHENA LAUTAN SAMUDERA
* AFTER ALL COMPLETE, PLEASE GIVE BACK THIS DOC RECEIVE CERTIFICAT TO THE BOARDING AGENT
* ALL DOCUMENT/SERTIFICATE ABOVE IS ORIGINAL AND ENSURE STILL VALID DATE
* ALL CERTIFICATE ABOVE AND PASSPORT WILL RECEIVING BY BOARDING AGENT WHEN THE VESSEL ARRIVAL FOR REPORT TO PORT AUTHORITY
AGENCY SHIPPING, CHARTERING AND FORWARDER
CV. ATHENA LAUTAN SAMUDERA
JL B Raya No. 11 RT. 005/ RW. 003 Kel. Rawabadak Utara Kac. Koja
Provinsi DKI Jakarta, Indonesia. Contact : +6281804900824 / +6285242336217
VESSEL NAME : MT. HD GOLD PORT : MUARA BERAU, SAMARINDA
VOY : 03/2024 DATE : MARCH 14TH, 2024
Please submit to us to the original of statutory certificates and vessel's documents for Harbor master
and Immigration granting purpose as follow :
Purpouse : In Out Clearance
No. Ship Certificate Arrival Departure Remark
1 Last Port Clearance
2 Registry Certificate
3 International Tonnage Certificate
4 International Load Line Certificate
5 Minimum Safe Manning Certificate
6 Cargo ship safety Construction Certificate
7 Cargo Ship Safety Equipment certificate
8 Cargo ship safety Radio Certificate
9 Safety Management Certtificate (S.M.C)
10 Document of Compliance (D.O.C)
11 Int. Oil Pollution Prevention Certificate (I.O.P.P)
12 Int. Air Pollution Prevention Certificate (I.A.P.P)
13 Int. Sewage Pollution Prevention Certificate (I.S.P.P)
14 NLS (Noxious Liquified Subtstance) / Fitness Cert.
15 Int. Ship Scurity Cert. (I.S.S.C)
16 Class Certificate
17 C.L.C
18 Port State Control (P.S.C)
19 Sanitation Certificate
20 Indonesia Health Book
21 Liferaft Certificate
22 Fire Extinguiser / CO2 Certificate
23 P&I Insurance
24 Wreck Removal Insurance
25 Int' Anti fouling system Cert.
26 Continous Sinopsis Record
27 GM Calculations (for Departure)
28 MSDS
29 Passport All Crew
30 Handphone Ops
For Indonesian Crews Only:
1 Certificate of Competency & Endorsement (Copy)
Additional Require Document :
1 N.O.R 5 Copies
2 Arrival Condition 5 Copies
3 IMO Ship's Crewlist (Arrival & Departure) 15 Copies
4 Ships Particular 5 Copies
5 Port Of Call 6 Copies
6 Cargo Manifest 5 Copies
7 Narcotic List / Drug store list 5 Copies
8 IMO Ship's Store List 3 Copies
9 IMO Crew's Effect Declaration 3 Copies
10 Bonded Store List 3 Copies
11 Stowage Plan 3 Copies
12 Vaccination List 2 Copies
13 Medical Chest Cert. (P3K) 2 Copies
14 Medical List 2 Copies
15 Maritime Declaration Of Health 2 Copies
16 Nil List 2 Copies
17 Daily temperatute list 2 Copies
Next port
Kindly acknowledge receipt of the above document by affixing your signature in this letter and return them
to vessel before sailing
Received by Boarding Agent Received by Master (Return back before sailing)
KARYADI * PIC of Boarding Agent :
Agent : CV ATHENA LAUTAN SAMUDERA
