Detail

(Regulation 45(2))

(Official Seal)
(COUNTRY)
CERTIFICATE
Photograph of holder of the Certificate
The Governor of Certifies that
has been found qualified in accordance with the provisions of regulation
of the shipping (Manning and Certification) Regulations, and
has been found competent to perform the following functions, at the levels specified, subject to any limitations indicated until or until the date
of expiry of any extension of the validity of this certificate as may be shown overleaf:
FUNCTION	LEVEL	LIMITATIONS APPLYING (IF ANY)


The lawful holder to this certificate may serve in the following capacity or capacities specified in the applicable safe manning requirements of the Minister or any person authorised by the Minister —
CAPACITY			LIMITATIONS APPLYING (IF ANY)


Certificate No. Issued on
(Official Seal)
					Signature of authorized official

					Name of authorized official
The original of this certificate must be kept available in accordance with the Shipping (Manning and Certification) Regulations while serving on a ship.
Date of birth of the holder of the certificate
Signature of the holder of the certificate
The validity of this certificate is hereby extended until

(Official seal)
					Signature of authorized official
Date of revalidation
					Name of authorized official
The validity of this certificate is hereby extended until

(Official seal)
				Signature of authorized official
Date of revalidation
				Name of authorized official

(Regulation 46(4))

(Official Seal)
(COUNTRY)
CERTIFICATE
Photograph of holder of the certificate
The Government certifies that certificate No.
has been issued to
who has been found qualified in accordance with the provisions of regulation of the
above Convention, as amended, and has been found competent to perform the following functions, at the levels specified, subject to any limitations indicated until
or until the date of expiry of any extension of the validity of this endorsement as may be shown overleaf:
FUNCTION	LEVEL		LIMITATIONS APPLYING (IF ANY)


The lawful holder of this endorsement may serve in the following capacity or capacities specified in the applicable safe manning requirements of the Minister or any person authorised by the Minister —
CAPACITY		LIMITATIONS APPLYING (IF ANY)

Endorsement No. Issued on
(Official Seal)

				Signature of authorized official

				Name of authorized official
The Original of this endorsement must be kept available while serving on a ship.
Date of birth of the holder of the holder of the certificate
Signature of the holder of the certificate
The validity of this endorsement is hereby extended until
(Official Seal)
Signature of authorized official
Date of revalidation
Name of authorized official
The validity of this endorsement is hereby extended until
(Official Seal)

				Signature of authorized official
Date of revalidation

				Name of authorized official

(Regulation 48(3))

(Official Seal)
(COUNTRY)
Photograph of holder of the certificate

The Government certifies that certificate No.
has been issued to who
has been found qualified in accordance with the provisions of regulation
of the above Convention, as amended, and has been found
competent to perform the following functions, at the levels specified, subject to any limitations indicated until or until the date of
expiry of any extension of the validity of this endorsement as may be shown overleaf —
FUNCTION	LEVEL	LIMITATIONS APPLYING (IF ANY)


The lawful holder of this endorsement may serve in the following capacity or capacities specified in the applicable safe manning requirements of the Minister or any person authorised by the Minister —
CAPACITY	LIMITATIONS APPLYING (IF ANY)

Endorsement No. Issued on
(Official Seal)
			Signature of authorized official

			Name of authorized official
The Original of this endorsement must be kept available while serving on a ship.
Date of birth of the holder of the holder of the certificate
Signature of the holder of the certificate
The validity of this endorsement is hereby extended until
(Official seal)
Signature of authorized official
Date of revalidation
Name of duly authorized official
The validity of this endorsement is hereby extended until
(Official seal)
Signature of duly authorized official
Date of revalidation
Name of duly authorized official

(Regulation 52(2))

Vessel Details

Name of vessel	IMO or Carib Ship Number (where applicable)						Official Number (if assigned)

Type of Vessel	Total Engine Power (K W)						Intended GMDSS Sea Areas in which the ship will sail (for ships over 300GT)
Gross Tonnage	Length (as per tonnage Certificate) (m)						Unattended Machinery Space (UMS)
ITC
National
Trading Area: UNRESTRICTED RESTRICTED (if restricted
give details, including any conditions imposed by Class on the sailing area/sea conditions)


Details of owner
Full Name of owner
IMO Number

PROPOSED MINIMUM COMPLEMENT
DECK					ENGINE
Rank		STCW reg.	No.			Rank		STCW reg.	No.
MASTER						MASTER
CHIEF OFFICER						SECOND ENGINEER
OFFICER IN CHARGE OF WATCH (OoW)						OFFICER IN CHARGE OF WATCH (OoW)
WATCH RATING						WATCH RATING
ORDINARY SEAFARER
Signature of Applicant				Print Name

Date of Application				Title