FOP-519

APPLICATION FOR THE ISSUE OF AN ADDITIONAL

STCW’78CERTIFICATE OF PROFICIENCY

A.PERSONAL PARTICULARS OF APPLICANT

SURNAME:...... FIRSTNAMES:......

DATE OF BIRTH: ...... COUNTRY OF BIRTH: ......

NATIONALITY: ...... ID NO./PASSPORT: ...... HEIGHT: ...... EYE COLOUR: ...... HAIR COLOUR: ......

PERMANENT ADDRESS: ......

......

TELEPHONE NO.:...... PORT: ......

GENDER / M / F / RACE / B / W / C / I
HOME LANGUAGE / ………………………………………………….

E-MAIL: ......

………………………………………….

Signature of Candidate

B.CURRENT CERTIFICATE OF COMPETENCY OR QUALIFICATION

(A certified copy of the abovementioned is to be attached to this application)

Certificate......

Certificate No.:Date of Issue: ......

  1. CERTIFICATE OF ADDITIONAL PROFICIENCY

Basic training (A-VI/1)Safety Familiarization training (A-VI/1)

Pre-Sea Training (STCW-F III/1)

Elementary First Aid (A-VI/1-3)Fire fighting and fire prevention(A-VI/1-2)

Medical first aid (A-VI/4-1)Advanced fire-fighting(A-VI/3)

Medical Care (A-VI/4-2)Personal survival techniques (A-VI/1-1)

Personal safety and social responsibilities (A-VI/1-4)

Proficiency in Survival Craft and rescue boats (A-VI/2-1)

Proficiency in Fast Rescue Boats (A-VI/2-2)Security awareness (A-VI/6-1)

Designated security duties training (A-VI/6-2)Ship Security Officer (A-VI/5)

Safety training for passenger ships (A-V/2) and Crowd management training (A-V/2)

Crisis management and human behavior training (A-V/2)

Passenger safety, cargo safety and hull integrity training (A-V/2)

Basic training for oil and chemical tankers (A-V/1-1-1)

Basic training for liquefied gas tankers (A-V/1-2-1)

Advanced training in oil tankers(A-V/1-1-2)

Advanced training in chemical tankers (A-V/1-1-3)

Advanced training in liquefied gas tankers (A-V/1-2-2)

  1. SUPPORTING DOCUMENTATION TO BE ATTACHED

Proof of Identity / 3 x Colour (I.D/passport) photos / Proof of qualifying service (if applicable) / Certificate of course passed at an accredited training institution / Previous certificate of additional qualification (if applicable ) / Basic training for oil and chemical tankers / Basic training for liquefied gas tankers
Basic training / x / x / x / x
Pre-Sea Training / x / x
Safety Familiarization training / x / x / x / x
Elementary First Aid / x / x / x / x
Medical first aid / x / x / x / x
Medical Care / x / x / x / x
Personal survival techniques / x / x / x / x
Personal safety and social responsibilities / x / x / x / x
Proficiency in Survival Craft and rescue boats / x / x / x / x
Proficiency in Fast Rescue Boats / x / x / x / x
Fire fighting and fire prevention / x / x / x / x
Advanced fire fighting / x / x / x / x
Basic training for oil and chemical tankers / x / x / x / x
Basic training for liquefied gas tankers / x / x / x / x
Advanced training in oil tankers / x / x / x* / x / x / x
Advanced training in chemical tankers / x / x / x* / x / x / x
Advanced training in liquefied gas tankers / x / x / x* / x / x / x
Security awareness / x / x / x / x
Designated security duties training / x / x / x / x
Ship Security Officer / x / x / x $ / x / x

*3 months sea service required

$ 12 months sea service served on trading ships >500GT

Safety training for passenger ships / Crowd management training / Crisis management and human behavior training / Passenger safety, cargo safety and hull integrity training
Proof of Identity and 3 x photographs (I.D. Size) (Black & White) / x / x / x / x
Certificate of course passed at an accredited training institution / x / x / x / x
Previous certificate of additional qualification (if applicable ) / x (see
note) / x / x / x

NOTE: Safety Training course not required if served for one year in the preceding five years, appropriate to the type of passenger

vessel for which the endorsement is required.

E.SEA SERVICE FOR A CERTIFICATE OF ADDITIONAL PROFICIENCY

Particulars of sea service should be taken from the Seaman’s Record Book and / or Certificate of Discharge

Name of Ship / Official Number / Gross Tonnage and type of vessel / Type of Service (Unlimited, near - coastal, port operations / Capacity / Dates / Actual Period / Assessed Period
From / To / Months / Days / Months / Days
Net qualifying service

………………………......

DateSignature of examiner

FOR OFFICE USE ONLY

Fee received: ...... Receipt No.: ...... Date: ………………………

......

Signature of personreceiving the feeSignature of Candidate

I have checked the above documents and I amsatisfied that the candidate may be issued with aCertificate of Additional Proficiency as

Certificate of ProficiencySTCW Reference

  • Elementary First AidA-VI/1-3
  • Medical First AidA-VI/4-1
  • Medical CareA-VI/4-2
  • Personal Survival TechniquesA-VI/1-1
  • Personal Safety and Social ResponsibilitiesA-VI/1-4
  • Fire Prevention and Fire FightingA-VI/1-2
  • Advanced Fire FightingA-VI/3
  • Basic TrainingA-VI/1
  • Survival Craft and Rescue BoatsA-VI/2-1
  • Fast Rescue BoatA-VI/2-2
  • Basic Training – Oil and Chemical TankersA-V/1-1-1
  • Basic Training – Liquefied Gas TankersA-V/1-2-1
  • Advanced Training – Oil TankersA-V/1-1-2
  • Advanced Training – Chemical TankersA-V/1-1-3
  • Advanced Training – Liquefied Gas TankersA/V/1-2-2
  • Designated Security DutiesA/VI/6-2
  • Ship Security OfficerA/VI/5
  • Security AwarenessA/VI/6-1
  • Crowd Management and Passenger SafetyA-V/2
  • Passenger Safety, Cargo Safety and Hull IntegrityA-V/2
  • Crisis Management and Human BehaviourA-V/2
  • Pre-sea TrainingSTCW-F III/1

Applicable Regulations

  • Merchant Shipping (Safe Manning, Training and Certification) Regulations 2013, as amended
  • International Convention on Standards of Training, Certification and Watchkeeping for Fishing Vessel Personnel, 1995

Level

  • Management
  • Operational
  • Support
  • N/A

At the port of ...... this…...... day of......

...... ………………………………….

Name of Examiner (In block letters) Signature of Examiner

Revision No/ Date / Title / Page / Reference
7 – 29.04.14 / The issue of an additionalSTCW’78 certificate of proficiency / 1 of 4 / FOP-519