Sis Form 9 - Application For A Certificate Of Competency (Page 5 of 8) in pdf

Sis Form 9 - Application For A Certificate Of Competency Page 5

DECLARATION BY CANDIDATE

Any person who makes, or procures to be made, or assists in making, any false representation or

statement for the purpose of obtaining for him or herself or any other person a Certificate of

Competency, may be issued with a fixed payment notice or shall be liable on summary conviction

to a Class A fine or imprisonment or both.

I hereby declare that the particulars contained in this application form are correct and true to the

best of my knowledge and belief; and that the substantiating documentation sent with this form are

true and genuine documents, given and signed by the persons whose names appear on them. I

further declare that the form contains a true and correct account of the whole of my service.

I make this declaration believing the same to be true.

Signature of Applicant:

Note: Please keep signature within the box provided. This

signature will be scanned and printed into the certificate

applied for.

Date:

For Official Use Only:

Attach Seafarer’s

Photograph here

for scanning

FOR OFFICIAL USE ONLY

APPLICATION PASSED

I hereby certify that the particulars above are correct and that the candidate has produced

satisfactory testimonials, proof of training, service and nationality, and that the candidate has

qualified in all respects for a Certificate of Competency as follows:

Functions

Level

Capacity

STCW Reg Limitations applying

Approved Certificate Expiry Date:

Examiner’s Signature:

Office Stamp

Date:

APPLICATION REJECTED

I confirm that I have examined the training, service and other documents provided in support of this

application. I hereby certify that the candidate has NOT met the requirements for a Certificate of

Competency.

REASON(S) FOR REJECTION:

Examiner’s Signature:

Office Stamp

Date:

Sis Form 9 - Application For A Certificate Of Competency Page 5