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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


Pertamina Shipping
Jl. Yos Sudarso 32-34
Jakarta Utara - 14320

From

Mail Ref. No.


Date

:
:

Ships Name

Inspection Date

IMO No.

Inspection Port

Owner/Operator

Contact Person

Company Phone

Mobile Phone

E-mail

E-mail

(estimate)

(PIC for Inspection)

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

Certificate

Expiry Date
(dd/mmm/yy)

(Mention for other)

Expiry Date

Certificate

(dd/mmm/yy)

Class Certificate (H&M)

Safety Management Cert.

Load line Certificate

Document of Compliance

Safety Equipment Cert.

Gas Fitness Cert.

Safety Radio Certificate

Civil Liability Conv. (1992)(>2000DWT)

Safety Construction Cert.

Marine Pollution Insurance

(if applicable)

(>500GT)

IOPP Certificate
Applicant (Pemohon):

Sign

Company Stamp

Name
Position

Completed by Pertamina - SMR (Ass. Man. Vetting / Vetting Coordinator / Inspector)


Application form correctly completed?
Name
/
Inspection fees paid accordingly and pay-slip /
attached?

Date

Sign