Proforma (3 Sheets) for Dispensation (Age/Rank) on Engineering side

(1st two pages may be initialed, last page to be signed in full by the applicant)

(a)Particulars of Ship:

1 / Name of Ship
2 / Type of Ship
3 / Gross tonnage
4 / Port of Registry/Off. No.
5 / Main Propulsion Power (KW)
6 / Trading Area of Ship
7 / Date from which dispensation is required
8 / Any other information

(b)Particulars of the Seafarer/Rank for whom/which dispensation is sought:

1 / Full name
2 / Date of birth/Age Yrs.
3 / Nationality
4 / Grade of CoC & validity
5 / CoC No., Verification status
6 / Rank
7 / Any other information

(c)Details of dispensation sought:

1 / Name of company
2 / Reference of required letter (Letter no./dated
3 / Type of dispensation requested for (strike out as inapplicable) / Dispensation from Safe Manning/Age Dispensation/Permission to sail one rank lower to the Grade of CoC
4 / Period for which Dispensation is requested
5 / Grade for which Dispensation is requested
6 / Justification for dispensation request with documentary evidence as applicable (w.r.t
Annexure 1)
7 / Processing fee paid / YES/NO
8 / Any other information

(d)Playing details (for period during which dispensation is sought):

1 / Voyage duration (s), as applicable, in no. of days
2 / Sea-area of plying
3 / Prevailing weather condition
4 / Port visits (from & to)
5 / Duration of Port stay (s), in days
6 / Any other information, which will add clarity to the dispensation request

(e)Detention details (if applicable)

1 / Whether vessel has been detained in the previous six months. / YES/NO
2 / If Yes, list the major deficiencies, which led to detention.
6 / Any other information (relating to detention, including under Clause 17)

ANNEXURE – 1

Table for Manning (Engineering side)

Prescribed Manning as per Safe Manning Document
(Showing DCE or 0ther endorsement as applicable)
[1] / Present Manning provided at the time of application with age of each Officer
(e.g. P.S. Yadav, (64))
[2] / Position for which dispensation is requested for
[3] / Alternative(s) provided for by the company
[4] / Final Manning (Showing DCE / Other endorsements as applicable) to provide after grant of Dispensation sought from requirement of Safe Manning Document with age of each officer (*).
[5]

Applicant to maintain documentary evidence of compliance of Manning shown in this column (*)

(This column is not for Engineers of the vessel)

Name & Official Seal of the
Company seeking Dispensation :- / (Signature of Applicant) …………………………………………………………….….
(Name of D.P.A. / Company Officer as Applicant) …………………………
(Designation of Applicant) ……………………………………………………………
(Date of Application) …………………………………………………………………….