PT MUTUAGUNG LESTARI SPO APPLICATION FORM 1
BASIC INFORMATION INFORMASI STANDAR
1.1
Certification Body LembagaSertifikasi Certification submitted Sertifikasi yang diajukan
1.1.1
MUTUAGUNG LESTARI (Mutu Certification International)
Roundtable on Sustainable Palm Oil(RSPO) RSPO P & C
*) Mark as appropriate *) Tandai yang dipilih
RSPO New Planting Procedure RSPO-RED for Producers Indonesian Sustainable Palm Oil (ISPO)
1.1.2
1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.2.6 1.2.7 1.2.8
Client registration code Kode Registrasi Client Details of grower and mill/owner Informasi Perkebunan dan Pabrik Organisation name Nama organisasi Contact person Personal penghubung Business address Alamat Telephone Telepon Web page address Alamat website Fax Fax e-mail e-mail Is your organisation member of RSPO Apakah organisasi anggota RSPO RSPO Registration Number and Date*) Tanggl dan nomor keanggotaan RSPO
* Filled by Mutuagung Lestari
YES/ YA
NO / TIDAK
........................................................................
*) If
RSPO Certification Scheme *) Jika skema sertifikasi RSPO Fax Fax 1.3 1.3.1
SPO-4003.5
Scope of certification Ruang lingkup sertifikasi Type of certificate Tipe sertifikat
Single/Holding/Group
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM 1.3.2
Name of Palm Oil Mill (POM) and the location of POM (Nama Pabrik dan lokasi POM)
Village/ Sub district /District/Province/Country Desa/Kecamatan/Kabupaten/Provinsi/Negara
1.3.3
Name of Supply Base and the location (Nama pemasok dan lokasi)
Village/ Sub district /District/Province/Country Desa/Kecamatan/Kabupaten/Provinsi/Negara
1.3.4
Do you have smallholder schemes which supply FFB to your mill(s)? Apakah Perkebunan anda memiliki Pola Petani Kemitraan yang memasok ke Pabrik Kelapa Sawi tanda? If yes: Jika ya : Do you want to include in this scope of certification? Apakah anda ingin mengikut sertakan dalam ruang lingkup sertifikas iini ?
How many hectare(s) are they? Berapa Luas (Ha) pola kemitraan tersebut? What schemes are used? Pola Kemitraan apa yang digunakan ?
YES / YA
NO / TIDAK
YES / YA NO / TIDAK If yes, please attach on the Time bound plan Jika ya, mohon dilampirkan pada time bound plan *) If
RSPO Certification Scheme *) Jika skema sertifikasi RSPO
PIR-Trans/PIR-Bun/Full Manage KKPA/etc. .......................................................................
Where is the location? (please describe as appropriate) Dimana alokasinya?(harap dijelaskan)
1.4
Management Unit Unit Manajemen
1.4.1
Land ownership: Kepemilikan lahan : Private (ha)* Pribadi State (ha)* Negara Community (ha)* Masyarakat *Legality (Site Permit/land Used Title / Izin Usaha Perkebunan) *Legalitas (IzinLokasi/HakGuna Usaha / Plantation Business License) ........................................................................................
SPO-4003.5
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM 1.4.2
Total area (hectares) Total area (hektar) Planting Year TahunTanam
1.4.3
1.4.4
1.4.5
TOTAL Have your company been assessed by Indonesian Ministry of Agriculture for Plantation Classification Assessment Apakah Perusahaan / Perkebunan anda telah dilakukan Penilaian Kelas Kebun (PUP) oleh Dinas Perkebunan setempat ? If yes, please describe and issue date Jika sudah (Ya), mohon dijelaskan (penerbitan) What Class ( I, II, III, IV, V); date of issued; issued by; Kelas Apa ( I, II, III, IV, V); tanggal terbit; diterbitkanoleh; Have you done HCV identification or Conservation Area Statement in your operational area? Apakah sudah dilakukan identifikasi HCV atau Penetapan Kawasan Lindung di area operasional anda? If yes, Jika ya How many hectare(s) are there? Berapaluas (Ha) ? HCV Values present Kategori HCV apa saja? Non Palm oil Products or Services (area in ha) - if any Produk selain Produk KelapaSawit di area operasional – Jika ada
(please attach in other sheet if necessary) (Dapatmenyertailampiranjikadiperlukan) Hectarage / Luas(ha) Name of Estate Name of Estate NamaKebun NamaKebun
YES / YA
NO / TIDAK
YES / YA
NO / TIDAK
Total
Transportation model, time and distance from the nearest airport to the site Model transportasi, berapa lama dan jarak unit dari Bandar udara terdekat 1.5 1.5.1 1.5.2
SPO-4003.5
Others Information Informasi Lain Stage-1 Audit schedule Rencana dilakukan Stage-1 Stage-2 Audit schedule Rencana dilakukan Stage-2
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM 1.5.3 1.5.4
SPO-4003.5
Other certification obtained Jenis sertifikasi yang dimiliki Does your organisation using consultancy (body / person) in implementing the SPO systems. Apakah organisasi anda menggunakan jasa konsultansi (badan atau personal) dalam implementasi sistem SPO
YES / YA NO / TIDAK If yes, please write the name of body or persons : Jika ya, mohon tuliskan nama dari badan atau personel tersebut: ..................................................................................
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM 1.5 Details of plantation estate(s) and mill(s) – Please state below 1.5 Detil Perkebunan dan Pabrik Kelapa Sawit harap diisidibawahini 1.5.1 Description of Palm Oil Mill 1.5.1 Deskripsi Pabrik KelapaSawit Name of Mill(s) Nama Pabrik Kelapa Sawit
GPS Coordinate Koordinat GPS
Location Lokasi
Latitude Lintang
Village/Sub district/District/Province
X degree N/S
Longitude Bujur
Capacity (tonnes/hour) Kapasitas (ton/jam)
Annual Volume (tonnes) Volume tahunan (ton) CPO PK Output Output (tonnes) (tonnes)
X degree W/E
Desa/Kecamatan/Kabupaten/Provinsi
1.5.2 Description of Supply Base 1.5.2 Deskripsi kebun Pemasok FFB Supply Base(s) (Estate& other source) Nama Kebun
GPS Coordinate Koordinat GPS
Location Lokasi
Latitude Lintang
Village/Sub district/District/Province
X degree N/S
Longitude Bujur
Total Area (ha) Area total (ha)
Planted Area (ha) Area tertanam (ha)
FFB Production (tonnes/year) Produksi TBS (ton/tahun)
X degree W/E
Desa/Kecamatan/Kabupaten/Provinsi
Total
SPO-4003.5
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM 2.0. 2.0.
Area of plantation managed in holding, but exclude from scope of certification (Time Bound Plan) – for RSPO scheme Area perkebunan lain yang dikelola dalam satu holding, namun diluar dari ruang lingkup sertifikasi (Time Bound Plan) – skema RSPO (Please fill table below if your company managed more than one unit and/or one mill and/or one estate) (Harapdiisitabeldibawahinijikaperusahaan/group andamengelolalebihdarisatu unit manajemendan/atausatupabrikdan/atausatukebun) PALM OIL MILL PabrikKelapaSawit
Num No.
SUPPLY BASE (ESTATE) KebunPemasok
Company Perusahaan Name Nama
Company Name Nama Perusahaan
Company Shareholder Kepemilikan Saham Perusahaan
Company Perusahaan Location Lokasi
Name Nama
Company Name Nama Perusahaan
Company Shareholder Kepemilikan Saham Perusahaan
Location Lokasi
Total Area (ha) Total Area (Ha)
Planted Area (ha) Area Tertanam (ha)
1
2
3
For groups with complex management structures the following are required: (a) A statement of the ultimate controlling shareholders and directors in the managing agencycompany/companies. (b) Ditto in respect of each of the operating groups. (c) Application for membership by the top asset owning company/companies. (d) Application for membership by the managing agency company/companies.
SPO-4003.5
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Time Bound Plan Rencana Tata Waktu
PT MUTUAGUNG LESTARI SPO APPLICATION FORM DECLARATION PERNYATAAN I declare that the above information is true and i am duly authorised to sign this application. Saya menyatakan bahwa informasi diatas adalah benar dan saya berwenang untuk menandatangani aplikasi ini. I confirm that I’ve been made aware that PT MUTUAGUNG LESTARI is the primary registered office with the Roundtable on Sustainable Palm Oil (RSPO) and Indonesia Sustainable Palm Oil (ISPO) that handles all accreditation matters and in accepting any potential offers from any MUTUAGUNG LESTARI office for Sustainable Palm Oil (SPO) certification services, the contracting and legal office is PT MUTUAGUNG LESTARI Saya setuju dan memperhatikan PT MUTUAGUNG LESTARI adalah kantor pusat yang tergistrasi untuk RSPO dan ISPO yang menangani hal-hal akreditasi dan yang menerima tawaran dari beberapa kantor MUTUAGUNG LESTARI lainnya untuk jasa sertifikasi SPO, kesepakatan dan kantor legal adalah PT MUTUAGUNG LESTARI. I agree to give any additional information as required for the certification process and Mutuagung Lestari Sustainable Palm Oil (SPO) Certification Systems “Code of Practice”. Saya menyetujui untuk memberikan informasi tambahan yang dibutuhkan sesuai dengan proses sertifikasi dan Mutuagung Lestari Sustainable Palm Oil (SPO) Certification Systems “Code of Practice”
Signed on behalf Ditandatangani oleh
Tanggal
Date.....................................................
..................................................
*) Please send other document to complete information above in other sheet if necessary *)Mohon agar dapatmelengkapi data informasidiatasdengantambahanlampirandata jikadiperlukan.
SPO-4003.5
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM
APPLICATION FORM REVIEW KAJIAN FORMAT APLIKASI Mutuagung Lestari has reviewed the application form and we stating CONTINUED / DISCONTINUED*) for the next phase. Mutuagung Lestari telah melakukan kajian terhadap form aplikasi dan kami menyatakanMELANJUTKAN / TIDAK MELANJUTKAN*)pada proses berikutnya. Reason(s) : Alasan : No. 1
Items Audit team : - Lead Auditor
Justification / comments (please fill the blank)
-
2 3 4
Auditor Member (consider the local auditor who fluently communicate in local languages) - Technical Ex pert Reviewer Certification Committee Variable for considering the Audit Duration (man days) - Accessibility - Employee number - People languages -
Complexity of process Subcontractors involved
-
Specific regulation / requirement - Implementations of other systems (maturity of management systems) - Stakeholder Issues Man days Estimation Stage 1 Stage 2 Surveillance Recertification* Special Audit* Note : if applicable
5
Other reason (if any)
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PT MUTUAGUNG LESTARI SPO APPLICATION FORM
Signed on behalf Ditandatangani oleh Date..................................................... Tanggal
*) delete as appropriate *) coret yang tidakperlu
SPO-4003.5
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