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Form Iii - Application For Certificate Of Competency As A Coxswain/coxswain-Driver/driver

FORM III

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New

APPLICATION FOR CERTIFICATE OF COMPETENCY AS A

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Renewal

COXSWAIN/COXSWAIN-DRIVER/ DRIVER

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Upgrade

TO: Maritime Authority of Jamaica

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Re-issue of Certificate

Kingston

Licence No: _____________________________________

Issued on: _______________________________________

Pursuant to Rule 38 of the Harbour Rules, 1971, I hereby make an application for a Certificate of

Competency to operate a Coxswain/Coxswain- Driver/Driver *of a boat/vessel.

Full Name of Applicant _________________________________________________________________

Address of Applicant ___________________________________________________________________

Date of Birth _____________________________ Telephone Contact ___________________________

Tax Registration Number _______________________________________________________________

Name of Organization __________________________________________________________________

Previous Experience of Applicant: ________________________________________________________

____________________________________________________________________________________

Harbour/Harbours* within which the applicant desires to operate as a Coxswain/Coxswain Driver*:-

____________________________________________________________________________________

Type and Horsepower (B.H.P (kW) of the engine, which the applicant desires to operate as a Driver

/Coxswain Driver*: -

____________________________________________________________________________________

I submit herewith two (2) passport sized photographs of myself taken not more than three (3) months and

endorsed by a Justice of the Peace (JP), Inspector of Police or gazetted Police Officer.

DATED this ___________________day of ________________________ ______________________

Signature of Applicant

(Please sign in the box)

This is to certify that the applicant is to the best of my knowledge and belief, a person of good character

and sober habits, and has been known to me for a period of _________________________________ years.

_______________________________________

Inspector or Officer of Police/Justice of the Peace

For the parish of:________________________

/ Rev. No. 02/March 15, 2010

Form Iii - Application For Certificate Of Competency As A Coxswain/coxswain-Driver/driver