1 BASIC INFORMATION
INFORMASI STANDAR
1.1 Certification Body
LembagaSertifikasi MUTUAGUNG LESTARI (Mutu Certification International)
1.1.1 Certification submitted 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 anggota RSPO RSPO Registration Number and Date*) Tanggl dan nomor keanggotaan RSPO *) If RSPO Certification Scheme *) Jika skema sertifikasi RSPO
YES/ YA NO / TIDAK ... Fax Fax 1.3 Scope of certification
Ruang lingkup sertifikasi 1.3.1 Type of certificate
SPO-4003.5 Page2 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?
YES / YA NO / TIDAK
If yes: Jika ya :
Do you want to include in this scope of certification?
Apakah anda ingin mengikut sertakan dalam ruang lingkup sertifikas iini ?
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 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)
1.4.2 Total area (hectares)
Total area (hektar) (please attach in other sheet if necessary) (Dapatmenyertailampiranjikadiperlukan) Planting Year
TahunTanam
Hectarage / Luas(ha) Name of Estate
NamaKebun Name of Estate NamaKebun 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), 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;
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? Berapaluas (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 KelapaSawit di area operasional – Jika ada
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 Others Information
Informasi Lain 1.5.1 Stage-1 Audit schedule
Rencana dilakukan Stage-1 1.5.2 Stage-2 Audit schedule
SPO-4003.5 Page4 1.5.3 Other certification obtained
Jenis sertifikasi yang dimiliki
1.5.4 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:
1.5 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 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
SPO-4003.5 Page 6
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)
(Harapdiisitabeldibawahinijikaperusahaan/group andamengelolalebihdarisatu unit manajemendan/atausatupabrikdan/atausatukebun)
Num
No.
PALM OIL MILL
PabrikKelapaSawit
SUPPLY BASE (ESTATE)
KebunPemasok 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 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.
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
Date... Tanggal
...
*) Please send other document to complete information above in other sheet if necessary *)Mohon agar dapatmelengkapi data informasidiatasdengantambahanlampirandata jikadiperlukan.
SPO-4003.5 Page 8
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. Items Justification / comments (please fill the blank) 1 Audit team :
- Lead Auditor - Auditor Member
(consider the local auditor who fluently communicate in local languages)
- Technical Ex pert 2 Reviewer
3 Certification Committee
4 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
*) delete as appropriate *) coret yang tidakperlu
Signed on behalf
Ditandatangani oleh Date... Tanggal
