Form Mi-273 - Application For Seafarer'S Identification And Record Book And Special Qualifications

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(STAPLE DOCUMENTATION HERE)
THUMB PRINT
PHOTOGRAPH
See paragraph 3(b) of MI-273I.
Glue 1¾" X 1¾"
(45mm x 45mm) photo in
upper left hand corner.
See instructions for
detailed requirements
in paragraph 3(a) of MI-273I.
REPUBLIC OF THE MARSHALL ISLANDS
Office of the Maritime Administrator
APPLICATION FOR SEAFARER'S IDENTIFICATION AND RECORD BOOK
AND SPECIAL QUALIFICATIONS
1. LAST NAME (FAMILY NAME)
2. FIRST NAME (GIVEN NAME)
3. MIDDLE INITIAL
4. DATE OF BIRTH
5. PLACE OF BIRTH
6. CITIZENSHIP
MONTH
DAY
YEAR
CITY
COUNTRY
7. HEIGHT
8. WEIGHT
9. COLOR OF HAIR
10. COLOR OF EYES
11. SEX
FT
IN
LBS
Male
Female
12. DISTINGUISHING MARKS (SCARS, BIRTHMARKS, TATTOOS, ETC)
13. IS APPLICATION
NEW
REPLACEMENT
RENEWAL
Old Book No.
14. PERMANENT ADDRESS (STREET/CITY & COUNTRY)
15. MAILING ADDRESS FOR THIS DOCUMENT
16. LIST ALL MARSHALL ISLANDS DOCUMENTS
MI CERTIFICATE NO.:
CAPACITY:
SIRB:
17. PLEASE INDICATE HERE THE SPECIAL QUALIFICATIONS DESIRED:
:
TOTAL SQCs REQUESTED
18. I HEREBY AFFIRM THAT ALL INFORMATION PROVIDED BY ME IN THIS APPLICATION, ITS SUPPORTING DOCUMENTS AND PROOFS, IS
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF; FURTHER, THAT NO LICENSE, CERTIFICATE OR DOCUMENT
ISSUED TO ME HERETOFORE BY ANY GOVERNMENT HAS EVER BEEN REVOKED OR SUSPENDED. OR, IF REVOKED OR
SUSPENDED, A FULL EXPLANATION OF THE CIRCUMSTANCES IS ATTACHED HERETO AND MADE A PART OF THIS APPLICATION
MONTH
DAY
YEAR
DATE OF APPLICATION
TO BE SIGNED BY APPLICANT IN PRESENCE OF FILING AGENT
AFFIRMED BEFORE ME,
TYPE OR PRINT NAME OF FILING AGENT
REQUIRED DOCUMENTATION
Application (MI-273) completed and signed by applicant.
One (1) 1¾” x 1¾” (45mm x 45mm) photo showing facial front
SIGNATURE OF FILING AGENT
view attached and right thumb print applied.
Acceptable proof of identification submitted. Copy attached.
Certified translation provided if identity document is not in English.
Proof of STCW Basic Training.
FILING AGENT’S TITLE
Copy of physical exam submitted.
Letter of commitment for assignment to a Marshall Islands vessel
(for SIRB initial applications only).
FILING AGENT'S COMPANY
Requisite fee included.
Page 1 of 2
MI-273 (5/07)

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