South African
Maritime Safety Authority
SEAMAN’S RECORD BOOK NO: ......
Merchant Shipping Act, 1951 (Act 57 of 1951)
APPLICATION FOR A SEAMAN’S RECORD BOOK
New Issue Replacement of full book (No.: ...... ) Replacement of Lost / damaged book
(This application shall be accompanied by testimonials or other suitable proof of previous sea service,
together with two photographs of size 65 mm x 40 mm of the applicant and the prescribed fee).
A.
PARTICULARS OF APPLICANT
Surname(in block letters) / First names
(in block letters)
Contact Numbers:
Height / Colour of / Address
Eyes / Hair
Date of Birth / Place & Country of Birth
Any scars or tatoos
B.
NAME, RELATIONSHIP AND ADDRESS OF NEXT-OF-KIN OR NEAREST FRIEND
NameRelationship
Address
C.
TO BE COMPLETED BY APPLICANT
I hereby certify that the particulars appearing in this application are true and correct.
Date: ......
Signature of Applicant
Place: ......
D.
DETAILS OF CERTIFICATES OF COMPETENCY
Grade / No. / Issuing authority and dateE.
DETAILS OF CERTIFICATE OF SERVICE
Grade / No. / Issuing authority and dateF.
DETAILS OF TRAINING COURSES
Date of course / Particulars of course / Certificate obtainedG.
OTHER QUALIFICATIONS
(Certificate of Proficiency in Survival Craft, Certificate as Efficient: Deck Rating, Engine Room Rating and Cook).
......
......
H.
RECORD OF PREVIOUS SEA SERVICE
Date / Name of Ship / Description of voyage or employment (state whether foreign-going, coasting, fishing, etc) / Rank or rating / Ability / ConductFrom / To
I.
Declaration to be made by the applicant before a proper officer or a commissioner of oaths if application is made at a place where there is no proper officer.
I ...... the undersigned, of
...... (address)
hereby declare that my seamans record book No...... was issued at the port of ......
The said book is FULL / LOST / DESTROYED / MUTILATED / DAMAGED. The circumstances are the following:
......
......
......
DATE SIGNATURE OF APPLICANT
Declared before me at ...... on the ...... day of ......
......
SIGNATURE OF PROPER OFFICER OR
SIGNATURE OF COMMISSIONER OF OATHS
J.
To be completed by employer or person authorised by employer if application is made at a place
where there is no proper office.
* The ......
The application together with the prescribed fee is forwarded herewith for consideration, and I hereby certify that the particulars appearing on this form are to the best of my knowledge and true and correct, and that the two enclosed photographs bear a true likeness of the applicant.
Enclosures (testimonials, certificates, etc) ......
Address ......
Date ......
......
Signature & designation of employer
Company or or person authorised by him
Ships stamp
K.
FOR OFFICIAL USE ONLY
I hereby certify that Record Book No...... has been issued to the applicant whose photograph is affixed.
The fee of ...... has been brought to account (vide Receipt No......
dated ...... )
Photo of applicantPlace ......
Signature of Clerk
Official Stamp
South African
Maritime Safety Authority
REQUIREMENTS FOR THE ISSUE OF A
SEAMAN’s RECORD BOOK
Application form to be completed in full and all documents that are submitted are to be ORIGINALS.Fee of R400-00
Medical Certificate (Issued by a SAMSA approved Medical Practitioner)
Pre-Sea Course Certificate (for 1st time sea goers or proof of previous seatime)
2 x I.D. size photographs
Identity Document or Passport
A letter from your present Employer, certifying that you are employed on one of their vessels. Quoting the name of the vessel and the date of employment.
You must be a South African Seaman / Fisherman
or
be employed on a South African Registered vessel.
THIS BOOK IS TO RECORD ALL SEATIME - IT IS NOT A VISA