To be completed by the shipping company; for Dutch flagged vessels with registration in the Netherlands only. For VPD-protection of vessels with registration in Curaçao please contact Maritime Authority Curaçao. This application must be submitted to the following email address: bbk@kustwacht.nl The statutory timeframe [48 hours, weekends excluded] in which the Coastguard must make its decision on an application for armed private security will start once it receives this form, fully completed; attachments included.

For Coastguard use only:

Contact: | Nautisch Beheer/ WtBK

e-mail: | bbk@kustwacht.nl

Date: Time: | | KW dossiernr:

Urgency: □ Immediate response by Coastguard within 24 hours preferred? | Reason:

PART 1 – GENERAL INFORMATION

Details | Remarks

0 | Registration Dutch flag | Yes □ No □ | If ‘No’ Cancel request. This procedure is only applicable in case of Dutch flagged vessels.

1 | Company name | | Applicant must qualify as a ship manager under the Merchant Shipping (Protection) Act

2 | Address

3 | Areal code

4 | City

5 | Name of contact person(s)

6 | E-mail

7 | Telephone

8 | Name of ship

9 | Call sign

10 | IMO number

11 | Type of ship | | E.g. tanker, dry cargo, passenger ship, RoRo

12 | Photo of a side view of the ship | □ | Photo attached

13 | Number of crew members

14 | Attach copy of ship’s general plan (including accommodation plan) | □ | Copy of plan attached

Voyage Details

Details | Remarks

15 | Dates of transport: 1: Start [ETD] 2: End [ETA] | 1: 2:

16 | Last port of departure before the Risk Area

17 | First port of arrival after the Risk Area

18 | Intended route: Attach waypoint list. [RTZ, CSV, or Excel] | □ | Lat/Long WGS84 [ex. 29° 40 100N / 32° 33 200 E]

PART 2 – INITIAL RISK ANALYSIS OF THE TRANSPORT to be completed by the Company Security Officer

Details | Remarks

19 | Tonnage (Deadweight or Gross Tonnage) | □ DWT: □ GT:

20 | Free board on the Risk Area passage (metres/decimetres)

21 | Maximum speed

22 | Cruising speed during transport

23 | Time expected to be in the Risk Area: 1: ETA RA 2: ETD RA 3: Total time in (H)RA | 1: 2: 3:

24 | Manoeuvrability of the ship | Good / average / fairly poor / poor | Strike out what does not apply

25 | Weather sensitivity of the ship | Very sensitive / sensitive / less sensitive / not sensitive | Strike out what does not apply

26 | Cargo Specifications

27 | Information insurance cargo (like: type of insurance, name insurance company)

28 | Information insurance ship (like: type of insurance, name P&I or insurance company)

Initial risk analysis prior to application of own protection measures

Impact level: 1. Marine crime (ship stores) 2. Marine crime including exposure for crew 3. Piracy exposure 4. Severe injury / kidnap incident 5. Fatalities / Multiple severe injuries / Hijack of vessel | Frequency: Criteria1 o Exposure time in (High) Risk Area more than 48 hours o Increase of attacks in the last quarter according to IMB reports o Attacks reported last year according to IMB o Vessel speed alignment o Client / cargo resulting in extra exposure

Risk: High / Medium / Low. Drag the black dot to the appropriate field in the matrix

1 Mark if applicable: the sum of the markings is the frequency.

PART 3 – SECURITY MEASURES to be completed by the Company Security Officer

Mandatory measures according to Article 3 of the Merchant Shipping Protection Regulation: | Confirmation | Remarks Specify reason in case a box is not ticked

29 | Binoculars for the team on the bridge | □

30 | Search lights to check the surroundings of the ship | □

31 | Razor wire | □

32 | Locking access to the bridge, the crew and passenger quarters and the engine rooms | □

33 | Reinforcing large windows and portholes with bars or cover plates | □

34 | Designating crew muster point or safe room with means of communication with the outside world, such as VHF and/or INMARSAT | □

35 | Mounting water or foam sprayers | □

36 | Preparing the crew through anti-piracy exercises | □

37 | Protecting the ship’s equipment and machinery from third-party use | □

38 | Deploying fully trained crew members to one or more lookout posts, including the use of the bridge | □

Other:

39 | CCTV enabled? | □

40 | Lifts taken out of service? | □

41 | Other protective measures? Specify. | □...

OTHER CONSIDERATIONS

Have the following been considered: | Confirmation | Remarks Specify reason why it is not an option

42 | Taking a different route? | □

43 | Sailing in convoy? | □

44 | Hiring unarmed security personnel? | □

Residual risk assessment after application of own protection measures

Impact level: 1. Marine crime (ship stores) 2. Marine crime including exposure for crew 3. Piracy exposure 4. Serious injury / abduction 5. Fatalities / Multiple serious injuries / Hijacking of ship | Frequency: Criteria1 o Exposure time in high-risk area > 48 hours o Increase of attacks in the last quarter in the risk area according to IMB reports o Attacks reported last year according to IMB o Vessel speed alignment o Client / cargo resulting in extra exposure

Risk: High / Medium / Low. Drag the black dot to the appropriate field in the matrix

1 Mark if applicable: the sum of the marks is the frequency.

PART 4 – Armed Private Security PMSC QUOTES AND DISTANCE OF DETOUR FOR VPD EMBARKATION

Details | Remarks

45 | Quoted price PMSC (total price) | €/$

□ | Price offer PMSC attached

DETAILS OF PROPOSED PMSC

Details | Remarks

46 | Name of proposed PMSC / permit holder

47 | ILT permit number of PMSC

48 | Address / contact details of PMSC/permit holder

49 | Size of envisaged security team

50 | E-mail address of PMSC

51 | Proposed embarkation point of PMSC

52 | Proposed disembarkation point of PMSC

53 | Specify location & describe weapons storage of arms and ammunition on board when the ship sails outside of the (High) Risk Area

54 | Does the ship have a valid (interim-) International Ship Security Certificate (ISSC)? | N/A □ [< 500 GT] Yes □ No □ | If No, does it have an approved Ship Security Plan? Yes □ | No □

55 | E-mail address / telephone number of ship master

Part 5 – Vessel Protection Detachment from Ministry of Defence REGARDING THE VPD/ PCASP EMBARKATION

Details | Remarks

56 | What is the total number of persons for which Life-Saving Appliances are provided mentioned on the ships’ Safety Certificate? | | In case the actual total numbers of persons exceeds, contact the RO in order to obtain a temporary exemption.

57 | What is the ‘minimum safe manning’ number on board? | | According to the Minimum Safe Manning Certificate

58 | Extra accommodation (cabins) available?

59 | How many additional beds are available?

60 | Description of medical facilities on board

□ I have completed this form correctly to the best of my knowledge.

Name and position | Date | Signature