Documente Academic
Documente Profesional
Documente Cultură
Receipt No.
Document No.
2. Other names
yyyy:
1968
4. Gender
MALE
V 740098
INDONESIA
yyyy: 2012
SECTION 2
ParTICularS Of aPPlICaTION 8. Select all that are applicable 8.a Flag State Endorsement / Bahamas certificate Master Chief Mate Officer in Charge of a Navigational Watch Ratings forming part of Navigational Watch Chief Engineer
Online application
8.b Other Certificates/Documents Tanker Certificate/Endorsement CHEMICAL/GAS/OIL Ship Security Officer (SSO) Offshore Offshore Installation Manager (OIM)/ Maintenance Supervisor/Barge Supervisor/Ballast Control Operator
Ratings forming part of Engineering Watch GMDSS Radio Operator Second Engineer Officer in Charge of an Engineering Watch
DRILLING SERTIFICATE
SECTION 3
2.5567.97
No Expiry
Online application
Seamans Record Book 12. Name of ship in which the seafarer is to be employed 13. Capacity to be employed on board
SCARABEO 9
SECTION 4
I hereby declare that the personal details are true and correct, the photograph is a true likeness of me and the submitted supporting documents are of valid and authentic documents Signature of the seafarer Date dd:
Seafarer 1 2011
05
mm: 11 yyyy:
SECTION 5
14. Name
CONTaCT DETaIlS Of PErSON MaKING ThE aPPlICaTION Or TO whOM QuErIES CaN BE DIrECTED
Haisam Chaghoury
15. Company name (if applicable) 16. Email address 17. Telephone
haisam.chaghoury@gps.eni.it
+41 43 210 25 64
18. Fax
+41 43 210 22 01
SECTION 6
SECTION 7a
PayMENT DETaIlS Cheque/Bank draft Bank transfer Draw down account Credit card
SECTION 7b
PIETER DOMINGGUS
24. Type of card 25. Card No MasterCard Visa Solo Switch Amex 26. Expiry Date
4 0 9 7
6 2 1
4 1 8 9
6 1 1 1
2019
SECTION 9
I declare that I have verified the validity and authenticity of all submitted documents Name and signature of Company representative
Enrico Becagli
Date dd:
IMPORTANT NOTES:
Complete form in English using block capitals. All dates to be in dd/mm/yyyy format Applications using the online system should print the form after completing online, complete 8 (b) if other documents being requested, sign the form, and submit the form with any supporting documents Section 1, 4, 5, 6 and 7 to be completed for ALL postal Applications Application for duplicates/renewals should see guidance overleaf BMA Information Bulletin nos. 81, 86, 103, 104, 105, 106, 107, 108, 118, 121 provide more details guidance of the specific BMA requirements.
SECTION 1 ParTICularS Of SEafarEr (The relevant section will be pre-populated for on-line applications)
No. 1 No. 2 No. 3 No. 4 Enter only the surname of the seafarer as it appears on the appropriate certificate held. Use this box, if you only have one name Enter all other names as shown on the appropriate certificate held. Enter the seafarers date of birth in dd/mm/yyyy format Enter the nationality of the seafarer as itappears on the appropriate certificate or passport.
No. 5a Enter the ID/passport number of the seafarer as it appears on the passport/identity document. No. 5b Enter the primary nationality of the seafarer No. 6 No. 7 Enter the date of medical certificate of fitness. Note the certificate must be valid. Please only submit the pages of the certificate that shows identity of person and validity of certificate. See BMA Information Bulletin no. 103. Fix a passport sized photograph (5cm x 5cm) of the seafarer in the box with adhesive (do not use staples). Photographs may be scanned if the form is completed in an electronic format. Photographs must have be current (taken within 6 months of the date of application) and must be taken against a solid color background. Head coverings should not cover any portion of the applicants face. Sunglasses or other wear which detracts from the face are NOT acceptable with the exception of prescription glasses. If application being submitted using the on-line system, scan the photograph as JPEG format of at least 75 dpi resolution in this field
SECTION 3
If application being submitted using he on-line system, then tick the box and scan a sign copy of this form as a PDF with the submitted supporting documents. This section is only to be completed if the applicant is applying for a seaman record book No.12 No.13 Enter the name of ship that the applicant will be joining. Enter the capacity that the applicant will be serving onboard
Seafarer / Rev:00 / Date: 05 March 2010
SECTION 4
The seafarer shall sign and date the document in this Section. If the seafarer is not present, this should be noted in this Section and Section 9 MUST be completed. Note that it is a criminal offence to make a false representation or submit fraudulent documents
SECTION 5
This Section contains the contact details of the person or company representative submitting the application and to whom queries can be directed. This section must to be completed on Every form, as applications sent in together may become separated during the review process. No.14 No.15 State the name of the person or Company representative making the application Complete if application is submitting by a Company
SECTION 6
This Section contains the postal details where the issued document shall be sent. No.19 No.20 State the name of the Company State full postal address
SECTION 7a
No.21 Indicate how you will pay for the certificates/document by ticking the appropriate box
SECTION 9
The Company representative shall sign and date the document in this Section. Note that it is a criminal offence to make a false representation or submit fraudulent documents