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VETTING APPLICATION FORM

This form shall be completed as applicable and send to e-mail: smr@pertamina.com or directly addressed to SMR.
Incomplete data may result rejection or delay in the inspection schedule. Request to be submitted not later than 14
days before the inspection day. Inspection is preferable to be conducted during discharging.
Formulir ini harus diisi dengan benar dan dikirim ke e-mail: smr@pertamina.com atau langsung ditujukan kepada
SMR. Kurang lengkapnya data dapat mengakibatkan penolakan atau keterlambatan dalam jadwal pemeriksaan.
Permintaan untuk disampaikan selambat-lambatnya 14 hari sebelum inspeksi. Inspeksi diutamakan saat kapal
melakukan proses bongkar-muatan.

To: SMR Manager From :

Pertamina Shipping
Jl. Yos Sudarso 32-34
Mail Ref. No. :
Jakarta Utara - 14320
Date :
Ships Name Inspection Date (estimate)

IMO No. Inspection Port

Owner/Operator Contact Person (PIC for Inspection)

Company Phone Mobile Phone

E-mail E-mail
Ship Particular & Operational:

Ships Type Oil Gas Chem. Tanker SPOB OB TB (Other:....)

Charter Type LTTC TC COA Non-Charter (Other:)

GT & DWT Flag

Year of Built Classification Non Class

Length Over All mtr. Type of Cargo

Breadth mtr. Hull type Single Double - Hull

Mark as applicable system and or ships operational on board?

Pump room STS operational Mother Shuttle-Tanker

Inert gas system installation Single point mooring operation

Crude oil washing system Ice class (Mention for other)

Expiry Date Expiry Date

Certificate (dd/mmm/yy)
Certificate
(dd/mmm/yy)

Class Certificate (H&M) Safety Management Cert.

Load line Certificate Document of Compliance
Safety Equipment Cert. Gas Fitness Cert. (if applicable)

Safety Radio Certificate Civil Liability Conv. (1992)(>2000DWT)

Safety Construction Cert. Marine Pollution Insurance (>500GT)

IOPP Certificate
Applicant (Pemohon): Sign Company Stamp

Name

Position

Completed by Pertamina - SMR (Ass. Man. Vetting / Vetting Coordinator / Inspector) Sign
Application form correctly completed? / Name

Inspection fees paid accordingly and pay-slip / Date

attached?