Official Use only Receipt No. Document No. Application for Seafarers Document PLEASE READ THE GUIDANCE NOTES BEFORE COMPLETING THIS FORM SECTION 1 ParTICularS Of SEafarEr 1. Surname 7. Photograph 2. Other names 3. Date of birth: dd: mm: yyyy: 4. Gender 5. Passport/National Identity No. 5b. Nationality 6. Date of expiry of Medical Certificate of fitness : dd: mm: yyyy: SECTION 2 aPPlICaTION fOr ENdOrSEmENT, BahamaS CErTIfICaTE Or OThEr SEafarEr CErTIfICaTE, If aPPlICaBlE 8. Tick only those that are applicable Put a tick on the appropriate box for ‘Flag State Endorsement’ or ‘Bahamas Certificate’. Guidance related to ‘Flag State Endorsement’ are detailed in BMA Informational Bulletin 108. Guidance related to ‘Bahamas Certificate’ are detailed in BMA Information Bulletin 104. 8.a Flag State Endorsement Bahamas Certificate Master Chief Mate Officer in Charge of a Navigational Watch Able Seafarer (Deck) Ratings forming part of Navigational Watch Chief Engineer Second Engineer Officer in Charge of an Engineering Watch Able Seafarer (Engine) Ratings forming part of Engineering Watch Electro-Technical Rating 8.b Other Certificates Please affix here Tanker Certificate/Endorsement CHEMICAL LIQUEFIED GAS OIL Ship Security Officer (SSO) Offshore: (Please tick relevant boxes below) Offshore Installation Manager (OIM): GMDSS Radio Operator Electro-Technical Officer The common requirements as specified in section 7.1 of the Bulletin 105 STCW Master (Ⅱ/2) CoC OR STCW chief Engineer (Ⅲ/2) CoC. Evidence of 3 months service on a MOU (For STCW management level CoC holders only). Evidence of 36 months service on a MOU including 18 months service in the capacity of a Barge Supervisor (Not required for STCW management level CoC holders). Documentary evidence of having successfully completed all components of training listed in 5.3.2 and 5.4.2 of the Resolution. Documentary evidence of having successfully completed an approved course of training meeting the requirements of paragraph 6.2 and table 6.2 of the Resolution. Section continues overleaf Seafarer / Rev:02 / Date: March 2012
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