/ MONGOLIA
MONGOLIA MARITIME ADMINISTRATION
APPLICATION FOR
DANGEROUS CARGO ENDORSEMENT
(SENIOR OFFICERS) / Mongolia Ship Registry Pte Ltd
133 New Bridge Road
#16-02 Chinatown Point
Singapore 059413
Tel: (65) 6225 0125
Fax: (65) 6225 0305
Email:
Website:

NOTE: Application should be made together with the supporting documents and a processing fee.

A. PARTICULARS OF APPLICANT

Name (In Block Letter, as in Identity Card / Passport)
Address / Tel
*NRIC/Passport No. / Date of Birth / Place of Birth / Nationality

B. DANGEROUS CARGO ENDORSEMENT REQUIRED(Tick as appropriate)

Master Chief Engineer Petroleum
Chief Mate Second Engineer LPG
Cargo Officer Chemical

C. PARTICULARS OF OFFICIAL DOCUMENT

Type of Document / Certificate No. / Issued by / Date of Issue
Certificate Of Competency
Tanker Familiarisation Certificate
Advanced Tanker Safety Certificate
Fire-fighting Certificate
Advance Fire-fighting Certificate
Others :

D. PARTICULARS OF SEA SERVICE ON TANKERS #

Port of / Type of / Date / Duration
Name of Ship / Registry / Tanker / kW / Rank / From / To / Month / Day
# / 1) / You must have a minimum of 6 months sea service on board tankers.

E. DECLARATION OF APPLICANT

I hereby declare that the particulars contained in this application are correct and true to the best of my knowledge and that the documents and certificates sent with this application are true and genuine documents, given and signed by the persons whose name appear on them.

…………………………………………………………………………….
Name (In Block) and Signature
*Owners / Agents / Person applying / Date: / Stamp/Seal
Telephone number: / Contact Person:
Email Address: / Mode of collection:
By Hand / Post

* Select as appropriate.

Notes:

Applicant must furnish the followings together with this application form:

i)Digital photograph:

  1. passport size – 35mm (width) x 45mm (height)
  2. format – JPEG only
  3. file size – not exceeding 200 KB
  4. resolution – 300 pixels per inch

ii)Copy of a valid STCW-95 Certificate of Competency with Endorsement;

iii)Copy of a valid STCW-95 Tanker Familiarisation Certificate or Sea Service Testimonial;

iv)Copy of a valid STCW-95 Advance Tanker Safety Certificate;

v)Copy of a valid STCW-95 Fire-fighting Certificate or Attestation Letter;

vi)Copy of a valid STCW-95 Advance Fire-fighting Certificate;

vii)Copy of Sea Service Testimonial (6 months);

viii)Copy of a valid Medical Fitness Certificate.

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