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1、靠泊转油补贴申请表（20_年月）ApplicationFormforFuelSwitchingIncentiveGrant(mm/yyyy)本申请表需每月5日(遇周末或节假日可延后至节假日后的第一个工作日)前提交给资料审核机构，列明每艘船舶在深圳港停泊期间使用低硫油情况。资料审核机构联系方式如下()：ThiscompletedformmustbesubmittedtotheinformationverificationorganizationontheFifthofeverymonth(ifthedaylandsonweekendsorpublicholidays,thesubmissiond
2、aywillbeonthenextweekday),withdetailsindicatingeveryvessel,susingoflowsulfurfuelwhileberthingatShenzhenPort.Thecontactoftheverificationorganizationisasbelow:机构名称NameoftheOrganization深圳巾船舶代理学会地址AddreSs:深圳市F行山区南海大道联合大厘901室联系人ContaCtPerson电ISTelephone：孔小燕传真FaX电子邮箱Email第一部分企业基本信息PartIParticularsofCompan
3、y企业名称NameofCompany地址AddreSSofCompany法人代表LegaIPerson国籍NationaliIy负责人ReSPonSibIePerson电话TelePhone传真FaX移动电话MObiIePhone电邮Email联络人COntaCtPerson电话TeIePhone传真FaX移动电话MobiIePhone电邮Email户名BankAccountName开户行BankName账号BankAccountNumber第二部分泊岸转油实施情况（依船舶名称排序）序号SequenceNumber船舶名称VesselName呼号CallSign深圳市交通运输委登记编号Tran
4、sportCommissionofSZRegistrationNumber航次VoyageNo.靠泊地点BerthingLocation靠泊日期时间ArrivalTime(atBerth)离泊转油日期时间FuelSwitchEndTime低硫油含硫量sulfurcontent(%mm)低硫油消耗量(吨)Lowsulfurfuelconsumed(Tons)备注Remark泊位号BerthNo.靠泊转油日期时间FuelSwitchStartTime离泊日期时间DepartureTime(fromBerth)12345678910日期(Date):(20年(Y)月(M)说明：靠泊地点填写序号，1盐
5、田、2蛇口、3赤湾、4妈湾、5大铲湾、6-其它(需注明)Remarks:Forberthinglocation,pleaseenterthesequencenumber:I-Yantian;2-Shekou;3-Chiwan;4-Mawan;5-Dachanbay;6-others(Pleaseindicate)第三部分企业承诺及声明书鉴于深圳市政府同意考虑本企业船舶因使用低硫油给予“补贴资金”，本企业作出以下承诺及声明：InconsiderationoftheShenzhenMunicipalGovernment,sagreeingtoconsidertheincentivegrantfor
6、theVesselusinglow-sulfurfuel,theCompany,herebyundertakeanddeclarethat-1 .本企业确认申请低硫油补贴资金的所有船舶，在靠泊深圳港后已立即展开转油程序，并在转油程序展开后一小时至船舶离港的停泊期间内，使用含硫量不超过0.5%或0.K的低硫油。TheCompanyconfirmsthattheVesselhasinitiatedthefuelswitchoverprocedureuponberthingatShenzhenPortandonlyfuelwithsulfurcontentnotmorethan0.5%or0.1%h
7、asbeenusedafteronehourfrominitiatingfuelswitchoperationandthroughoutremainingberthingperiod.2 .申请低硫油补贴资金时，需附上由轮机长签署加盖船章的低硫油交付单核证副本、显示船舶转用低硫油情况的机舱日志核证副本和油类记录簿核证副本。Whenapplyingfbrgovernmentgrantfbrthevesselsusinglowsulfurfuel,pleaseattachthecertifiedtruecopyoftheBunkerDeliveryNote,EngineRoomLogBook(in
8、dicatingtheusageoflowsulfurfuel)andOilRecordBook.AllthesedocumentsshallbesignedbytheChiefEngineerwithstampoftheVesselon.3 .本企业明白政府人员及/或其代表可登船查核任何有关泊岸转用低硫油的文件，有权抽取燃料样本，以核证船舶泊岸时转用低硫油。查核的相关文件包括但不限于低硫油交付单、油类记录簿、机舱日志，并同意保留前述文件最少一年以供查核。TheCompanyunderstandsthatanyGovernmentofficialand/orhisrepresentativeh
9、astherighttobeonboardtheVesselconductdocumentchecktoverifytheuseoflowsulfurfuelwhiletheVesselisatberthandagreetokeeprelevantdocuments,includingbutnotlimitedtotheBunkerDeliveryNote,OilRecordBookandEngineRoomLogBookfbratleastoneyearfbrinspection.4,本企业同意在政府人员或其代表提出要求时，在七个工作天内提交有关文件的核证副本及/或进一步资料作查核之用。Up
10、onrequest,theCompanyagreestosubmitthecertifiedtruecopyoftherelevantdocumentand/orfurtherinformationtotheGovernmentofficialorhisrepresentativeforverificationwithinsevenworkingdays.5 .本企业明白提供的材料、数据需真实有效，凡谎报、瞒报及提供虚假信息申请深圳港低硫油补贴资金的，深圳市政府有权追回。涉嫌犯罪的，深圳市政府将依照中华人民共和国有关法律追究相关人员的责任。TheCompanyunderstandsthatth
11、edocumentsanddatasubmittedmustbeauthenticandeffectiveandthatanypersonthatunder-reportsorusesfalseinformationtoapplyforthegovernmentgrantfortheVesselusinglowsulfurfuel,ShenzhenGovernmenthasarighttorequesttherefundofgrant.ThoseliabletocrimeswillbeprosecutedaccordingtotherelatedlawsofPRC.6 .本企业明白本申请表需每
12、月5日(遇周末或节假日可延后至节假日后的第一个工作日)前提交资料审核机构，列明每艘船舶在深圳港停泊期间使用低硫油情况。TheCompanyunderstandsthatthiscompletedformmustbesubmittedtotheinformationverificationorganizationontheFifthofeverymonth(ifthedaylandsonweekendsorpublicholidays,thesubmissiondaywillbeonthenextweekday),withdetailsindicatingeveryvessel,susingoflowsulfurfuelwhileberthingatShenzhenPort7 .本企业已仔细阅读上述承诺及声明内容，完全明白相应的义务及法律责任。TheCompanyhascarefullyreadtheprovisionsofthisUndertakingandDeclarationandfullyunderstandsitsobligationsandliabilities.日期企业负责人签署及盖章DateandSignatureoftheResponsiblePersonCompanyStamp
