GOVERNMENT OF INDIA

MINISTRY OF SURFACE TRANSPORT

DIRECTORATE GENERAL OF SHIPPING

Application for conversion of Fishing Vessel Certificate of Competency issued under the provisions of M.S. (Examination of Skippers and 2^nd Hand of Fishing Vessel) Rules 1964 or M.S. (Examination of Skipper and Mate of Fishing Vessels) Rules 1987 to Merchant Navy Certificate of Competency Restricted (R) under M.S. (STCW ) Rules 1998 [STCW 78/95 Convention]

 

 

 

 

 

 

 A.  PERSONAL PARTICULARS

 

1.  (a)  Grade of Examination _________________________(R)     Place of Examination ____________________

 

(b)    Full Name ______________________________________________________________________________
                (Block Letters)                                (Surname)                                            (Other Names)

 

2.  Permanent Address _________________________________________________________________________

3.  Present Address ___________________________________________________________________________

                                  ___________________________________________________________________________

                                 ____________________________________________________________________________

 

4.  Telephone Number (with STD Code) ___________________________________________________________

 

5.  Nationality (Proof to be produced) _____________________________________________________________

 

6.  Passport Number ___________________________________________________________________________

 

7.  Date & Place of issue _______________________________________________________________________

 

8.  Continuous Discharge Certification (C.D.C.) Number _____________________________________________

 

9.  Date & Place of issue _______________________________________________________________________

 

10. Date of Birth ___________________________ Place of Birth ______________________________________

     (Proof to be produced)

 

11. Personal identification Marks ________________________________________________________________

 

12. INDoS No ________________________________________________________________________________

 

Note: Any person who makes, causes to be made or assists in making any false representation for the purpose of obtaining for himself/herself or any persons a certificate, shall be liable for prosecution under the section of 182 & 420 of Indian Penal Code 1860.

B.  DETAILS OF SCHOLASTIC EDUCATION:
      (Separate sheets must be attached)

 

1.  Scholastic Education Level ____________________________________________________________________

 

2.  Principal Subjects ___________________________________________________________________________

 

3.  Year of Passing _____________________________________________________________________________

 

4.  School/College/Board ________________________________________________________________________

 

5.  Address of the Institution ______________________________________________________________________

 

C.  DETAILS OF SEA-GOING SERVICE (FOR DECK DEPARTMENT PRESONNEL).

 

D.  PARTICULARS OF STCW CONVENTION MODULAR COURSES (POST-SEA)

 

 
E.  PREVIOUS CERTIFICATION.

 

DECLARATION TO BE MADE BY THE CANDIDATE.

I hereby declare that the particulars contained in the form are correct and true to the best of my knowledge and belief and that papers enumerated and sent with this form are true and genuine documents given and signed by the person whose name appears on them. I further declare that Section D contains a true and correct account of my sea-going service without exception and I make this declaration conscientiously believing the same to be true.

The above declaration was signed in my presence

 

------------------------------------

Signature of Candidate

Examiner of Masters and Mates, Mercantile Marine Department

 

 ___________________________________________District

F.  REMARKS OF HEAD OF ASSESSMENT CENTRE

 

Eligible Category ______________________________ (as under relevant M.S. Notice)

 

 

Signature

 

 

Name ________________________________________ Official Stamp ___________________________

 

G.  REQUEST FOR ALLOTMENT OF SEAT FOR EXAMINATION:
 

 
H.   RESULT OF EXAMINATION
 

 

 

 

I.  REPORT OF EXAMINATION CENTRE.

 

1.   I hereby certify that _________________________________________________________________ has

satisfactorily produced testimonials and proof of sea-going service/watch-keeping service required for the grade.

 

2.      The candidate complies with M.S. Notice No _______ ./2003 issued under provisions of the examination of the Merchant Shipping Standards (Standards of Training Certification and Watch-keeping for Seafarers) Rules 1998 for the grade of ________________________________(R)
 

3.   The candidate has passed his examinations as under:

4.   Therefore candidates meets the requirement for issuance of C.O.C. as _______________________________ (R)

The Certificate of Competency may be forwarded to the Mercantile Marine Department Mumbai / Kolkata / Chennai / Kochi / Visakhapatnam / Tuticorin/Jamnagar or Indian diplomatic mission at _________________________________ (Under intimation to this department).

Examiner of Master and Mates Mercantile Marine Department, _____________________________

 

J.  FINAL ASSESSMENT PRIOR CERTIFICATION
 

 

CERTIFICATE FOR COMPETENCY GRADE ___________________________(R) AS RECOMMENDED BY MERCANTILE MARINE DEPARTMENT MAY BE ISSUED.

 

ASSESSOR AT DIRECTORATE GENERAL OF SHIPPING FOR MASTERS AND MATES.

  

 

REMARKS _______________________________________________________________________________________


 

 

_____________________
CHIEF EXAMINER
(MASTERS AND MATES)