/ / REPUBLIC OF THE PHILIPPINES /
DEPARTMENT OF TRANSPORTATION
/ MARITIME INDUSTRY AUTHORITY /
DECLARATION OF AFFILIATION

DIRECTIONS: Please indicate/declare ALL your affiliations with the following institutions. Please write N/A for those which are not applicable. Any change/ update on the information stated below shall be communicated to the Monitoring Division.Updating shall be done annually. Please use extra sheet,if necessary.

Name of Personnel: / Position:
Nature of Appointment: / Address & Contact Information:
  1. MARITIME TRAINING INSTITUTION (MTI)

NAME OF INSTITUTION / ADDRESS / TELEPHONE NUMBER / POSITION HELD / STATUS OF EMPLOYMENT/
CONNECTION
(Regular/On-call) / DATE OF APPOINTMENT / END OF CONTRACT
1
2
3
4
  1. ASSESSMENT CENTER (AC)

NAME OF INSTITUTION / ADDRESS / TELEPHONE NUMBER / POSITION HELD / STATUS OF EMPLOYMENT/
CONNECTION
(Regular/On-call) / DATE OF APPOINTMENT / END OF CONTRACT
1
2
3
4
  1. MARITIME HIGHER EDUCATION INSTITUTION (MHEI)

NAME OF INSTITUTION / ADDRESS / TELEPHONE NUMBER / POSITION HELD / STATUS OF EMPLOYMENT/
CONNECTION
(Regular/On-call) / DATE OF APPOINTMENT / END OF CONTRACT
1
2
3
4
  1. MANNING AGENCY

NAME OF INSTITUTION / ADDRESS / TELEPHONE NUMBER / POSITION HELD / STATUS OF EMPLOYMENT/
CONNECTION
(Regular/On-call) / DATE OF APPOINTMENT / END OF CONTRACT
1
2
3
4
  1. SHIPPING COMPANY

NAME OF INSTITUTION / ADDRESS / TELEPHONE NUMBER / POSITION HELD / STATUS OF EMPLOYMENT/
CONNECTION
(Regular/On-call) / DATE OF APPOINTMENT / END OF CONTRACT
1
2
3
4
  1. MARITIME EQUIPMENT SUPPLIER

NAME OF INSTITUTION / ADDRESS / TELEPHONE NUMBER / POSITION HELD / STATUS OF EMPLOYMENT/
CONNECTION
(Regular/On-call) / DATE OF APPOINTMENT / END OF CONTRACT
1
2
3
4

I hereby declare and confirm that I caused the preparation and submission of this Declaration of Affiliation and that I have read all the information indicated herein and attest to the truthfulness and correctness of the same to the best of my knowledge.

I undertake that I shall advise MARINA of any circumstance known to me that will give rise to an actual or potential Conflict of Interest involving me or my Affiliate.

In case of any conflict of interest situation, I will (1) inhibit myself from any direct or indirect participation or involvement at any stage of the monitoring or inspection activity, including decision making process and the signing of any paper or document related thereto; and (2) refrain from seeking to influence any action or avoid any action or inaction on my part that gives or will give indirect preferential treatment to my Affiliate.

I will comply with such other requirements prescribed by MARINA for purposes of enabling the verification of the declarations contained herein and monitor or ensure compliance with my foregoing undertakings.

______

Printed Name over Signature Date Accomplished

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