PT MUTUAGUNG LESTARI
SPO APPLICATION FORMSPO-4003.4 Page 1
1 BASIC INFORMATION
INFORMASI STANDAR
1.1 Certification Body
Lembaga Sertifikasi MUTUAGUNG LESTARI (Mutu Certification International) 1.1.1 Certification followed
Sertifikasi yang diajukan *) Mark as appropriate *) Tandai yang dipilih
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 Client registration code
Kode Registrasi Client * Filled by Mutuagung Lestari
1.2 Details of grower and mill/owner
Informasi Perkebunan dan Pabrik
1.2.1 Organisation name Nama organisasi 1.2.2 Contact person Personal penghubung 1.2.3 Business address Alamat 1.2.4 Telephone Telepon
1.2.5 Web page address
Alamat website
1.2.6 Fax
Fax
1.2.7 e-mail
1.2.8 Is your organisation member of RSPO
Apakah organisasi anda anggota RSPO
RSPO Registration Number and Date*) Tanggal dan nomor keanggotaan RSPO *) If RSPO Certification Scheme
*) Jika skema sertifikasi RSPO
YES / YA NO / TIDAK
...
1.3 Scope of certification Ruang lingkup sertifikasi 1.3.1 Type of certificate
Tipe sertifikat Single / Holding / Group
1.3.2 Location of plantation
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SPO APPLICATION FORMSPO-4003.4 Page 2
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?
YES / YA NO / TIDAK 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 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
How many hectare(s) are they?
Berapa luas (ha) pola kemitraan tersebut?
What schemes are used?
Pola Kemitraan apa yang digunakan ?
PIR-Trans/PIR-Bun/Full Manage KKPA/etc. ...
Where is the location? (please describe as appropriate)
Dimana lokasinya?(harap dijelaskan)
Village / Sub district / District / Province / Country
Desa / Kecamatan / Kabupaten / Provinsi / Negara
1.3.4 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: ... 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 / Plantation Business License)
*Legalitas (Izin Lokasi / Hak Guna Usaha / Izin Usaha Perkebunan)
...
1.4.2 Total area (hectares)
Total area (hektar) (please attach in other sheet if necessary) (dapat menyertai lampiran jika diperlukan)
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SPO APPLICATION FORMSPO-4003.4 Page 3
TahunTanam Name of Estate
Nama Kebun Name of Estate Nama Kebun Total
TOTAL
1.4.3 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 ?
YES / YA NO / TIDAK
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;
1.4.4 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?
YES / YA NO / TIDAK If yes,
Jika ya
How many hectare(s) are there?
Berapa luas (Ha) ?
HCV Values present
Kategori HCV apa saja?
1.4.5 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 1.5.1 Stage-1 Audit schedule
Rencana dilakukan Stage-1
1.5.2 Stage-2 Audit schedule
Rencana dilakukan Stage-2
1.5.3 Other certification obtained
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SPO APPLICATION FORMSPO-4003.3 Page 4
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 Location Lokasi GPS Coordinate
Koordinat GPS (tonnes/hour) Capacity Kapasitas
(ton/jam)
Annual Volume (tonnes)
Volume tahunan (ton)
Latitude
Lintang Longitude Bujur
CPO Output (tonnes) PK Output (tonnes)
Village / Sub district / District / Province
Desa / Kecamatan / Kabupaten / Provinsi
X degree N/S X degree W/E
1.5.2 Description of Supply Base 1.5.2 Deskripsi kebun Pemasok
FFB Supply Base(s) (Estate & other
source)
Nama Kebun
Location
Lokasi
GPS Coordinate
Koordinat GPS Total Area (ha) Area total (ha) Planted Area (ha) Area tertanam (ha) FFB Production (tonnes/year) Produksi TBS (ton/tahun) Latitude
Lintang Longitude Bujur Village /Sub district / District / Province
Desa / Kecamatan / Kabupaten / Provinsi
X degree N/S X degree W/E
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SPO APPLICATION FORMSPO-4003.3 Page 5
2.0. Area of plantation managed in holding, but exclude from scope of certification (Time Bound Plan) – for RSPO scheme
2.0. 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)
Num No.
PALM OIL MILL
Pabrik Kelapa Sawit SUPPLY BASE (ESTATE) Kebun Pemasok
Total Area (ha) Total Area (Ha) Planted Area (ha) Area Tertanam (ha) Time Bound Plan Rencana Tata Waktu Name Nama Company Perusahaan Location
Lokasi Name Nama
Company Perusahaan Location Lokasi Company Name Nama Perusahaan Company Shareholder Kepemilikan Saham Perusahaan Company Name Nama Perusahaan Company Shareholder Kepemilikan Saham Perusahaan 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
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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.
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SPO APPLICATION FORMSPO-4003.4 Page 7
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 : ... ... ... ... ... ... ... ... ... ... ... ... ... *) delete as appropriate
*) coret yang tidak perlu
Signed on behalf Ditandatangani oleh Date...
Tanggal
