PT MUTUAGUNG LESTARI SPO APPLICATION FORM 1
BASIC INFORMATION INFORMASI STANDAR
1.1
Certification Body Lembaga Sertifikasi Certification followed Sertifikasi yang diajukan
1.1.1
*) Mark as appropriate *) Tandai yang dipilih
MUTUAGUNG LESTARI (Mutu Certification International)
Roundtable on Sustainable Palm Oil (RSPO) RSPO P & C 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 anda anggota RSPO RSPO Registration Number and Date*) Tanggal dan nomor keanggotaan RSPO *) If
* Filled by Mutuagung Lestari
YES / YA
NO / TIDAK
........................................................................
RSPO Certification Scheme skema sertifikasi RSPO
*) Jika 1.3 1.3.1 1.3.2
SPO-4003.4
Scope of certification Ruang lingkup sertifikasi Type of certificate Tipe sertifikat Location of plantation Lokasi perkebunan
Single / Holding / Group Village / Sub district / District / Province / Country Desa / Kecamatan / Kabupaten / Provinsi / Negara Page 1
PT MUTUAGUNG LESTARI SPO APPLICATION FORM
1.3.3
Do you have smallholder schemes which supply FFB to your mill(s)? Apakah perkebunan anda memiliki Pola Petani Kemitraan yang memasok ke Pabrik Kelapa Sawit anda? If yes: Jika ya : Do you want to include in this scope of certification? Apakah anda ingin mengikutsertakan dalam ruang lingkup sertifikasi ini ?
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 skema sertifikasi RSPO
*) Jika
1.3.4
How many hectare(s) are they? Berapa luas (ha) pola kemitraan tersebut? What schemes are used? Pola Kemitraan apa yang digunakan ? Where is the location? (please describe as appropriate) Dimana lokasinya?(harap dijelaskan)
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
1.4
Management Unit Unit Manajemen
1.4.1
Land ownership: Kepemilikan lahan : Private (ha)* Pribadi State (ha)* Negara Community (ha)* Masyarakat
PIR-Trans/PIR-Bun/Full Manage KKPA/etc. ....................................................................... Village / Sub district / District / Province / Country Desa / Kecamatan / Kabupaten / Provinsi / Negara
YES / YA NO / TIDAK If yes, please write the name of body or persons : Jika ya, mohon tuliskan nama dari badan atau personel tersebut: ..................................................................................
*Legality (Site Permit / land Used Title / Plantation Business License) *Legalitas (Izin Lokasi / Hak Guna Usaha / Izin Usaha Perkebunan)
1.4.2
Total area (hectares) Total area (hektar) Planting Year
SPO-4003.4
........................................................................................ (please attach in other sheet if necessary) (dapat menyertai lampiran jika diperlukan) Hectarage / Luas (ha) Page 2
PT MUTUAGUNG LESTARI SPO APPLICATION FORM 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), tolong dijelaskan (penerbitan). What Class ( I, II, III, IV, V); date of issued; issued by; Kelas Apa ( I, II, III, IV, V); tanggal terbit; diterbitkan oleh; 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? Berapa luas (Ha) ? HCV Values present Kategori HCV apa saja? Non Palm oil Products or Services (area in ha) - if any Produk selain Produk Kelapa Sawit di area operasional – Jika ada
1.4.6
Transportation mode, time and distance from the nearest airport to the site Moda transportasi, berapa lama dan jarak unit dari Bandar udara terdekat
1.5
Others Information Informasi Lain Stage-1 Audit schedule Rencana dilakukan Stage-1 Stage-2 Audit schedule Rencana dilakukan Stage-2 Other certification obtained Jenis sertifikasi yang dimiliki
1.5.1 1.5.2 1.5.3
SPO-4003.4
Name of Estate Nama Kebun
Name of Estate Nama Kebun
YES / YA
NO / TIDAK
YES / YA
NO / TIDAK
Total
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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 diisi dibawah ini 1.5.1 Description of Palm Oil Mill 1.5.1 Deskripsi Pabrik Kelapa Sawit 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-4003.3
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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) (Harap diisi tabel dibawah ini jika perusahaan/group anda mengelola lebih dari satu unit manajemen dan/atau satu pabrik dan/atau satukebun) PALM OIL MILL Pabrik Kelapa Sawit
Num No.
SUPPLY BASE (ESTATE) Kebun Pemasok
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 agency company/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-4003.3
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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. 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 menyatakan bahwa informasi diatas adalah benar dan saya berwenang untuk menandatangani aplikasi ini. 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
Date..................................................... Tanggal
..................................................
*) Please send other document to complete information above in other sheet if necessary *) Mohon agar dapat melengkapi informasi diatas dengan tambahan lampiran data jika diperlukan.
SPO-4003.4
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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 stated to PROCEED / NOT PROCEED*) on the next phase. Mutuagung Lestari telah melakukan kajian terhadap form aplikasi dan kami menyatakan MELANJUTKAN / TIDAK MELANJUTKAN*) pada proses berikutnya. Reason(s) : Alasan : ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ........................................................................................................................................................................................................... ...........................................................................................................................................................................................................
Signed on behalf Ditandatangani oleh Date..................................................... Tanggal
*) delete as appropriate *) coret yang tidak perlu
SPO-4003.4
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