MSC PROMOTIONAPPLICATIONFORM

(CurrentMSC Civil ServiceMarinerEmployeesmustusethis formtoapplyfor MeritPromotion)

Position Name: Second Officer Announcement Number: 18-106-01MP

Last Name Click here to enter text.

First Name Click here to enter text.Coastal Preference

Middle InitialClick here to enter text.EastWestBoth

Mailing Address or Ship Address Click here to enter text. ☐ ☐ ☐

City Click here to enter text.StateClick here to enter text.ZipCode Click here to enter text.

E-Mail Address Click here to enter text.

Daytime Phone Number (include area code) Click here to enter text.

Evening Phone Number (include area code) Click here to enter text.

U.S.COASTGUARDLICENSESANDDOCUMENTINFORMATION:TypeallU.S.CoastGuardMerchantMarine Documents/Credentials, TWIC,STCW,etcthatarelistedundertheMinimumEligibilityRequirementsSectionof thePOA.For Logistics,Culinary,andPurserPOAs;Typeallprofessionalcertifications,qualifications,training,CertificateofRegistry,etcthat arelistedundertheMinimumEligibilityRequirementsSectionofthePOAs.

Typeof
License/Certificate/Document/Endorsement / ExpirationDate / LimitationsEndorsementonLicenses (if applicable)

APPLICANTCERTIFICATIONANDRELEASEOFINFORMATION:

I certifythat,tothebestofmyknowledgeandbelief,allof theinformationonandattachedtothisapplicationistrue,correct, completeandmadeingoodfaith.I understandthatfalseorfraudulentinformationonorattachedtothisapplicationmaybe groundsfor firingmeandmaybepunishablebyfineorimprisonment.I understandthatanyinformationI givemaybeinvestigated.I consenttothereleaseofinformationaboutmyphysicalabilityandfitnessbyemployers,schools,lawenforcementagenciesand otherindividualsandorganizations,toinvestigators,personnelist,andotherauthorizedemployeesoftheFederalGovernment.

Print or Type Full NameSignatureDate Signed

ForOfficialUseOnly –PrivacySensitive.Anymisuseorunauthorizeddisclosuremayresultinbothcivilor criminalpenalties.