The Merchant Shipping (Examination of Masters and Mates) Rules, 1985

APPENDIX "H"

[See rules 14(1), 16(1), 19, 35(Proviso), 36(3) (Proviso), 37(Proviso), 42, 65(2), 66, 69(1), 70(2) and 70(4)]

FORM B- Form of Certificate of Watch keeping

FORM C- Form of Certificate of Physical Fitness.

FORMD- Form of Conditional letter of Authority for Delivery of Certificate of Competency

FORM E- Form of application for Navy Limited Examination for Masters, and Mates of Foreign going and Home Trade ships.

FORM F- Form of letter of Authority for Delivery of the Certificate of Competency.

FORM G- Form of Result of Examination for Certificate of Competency.

FORM H- Form of Application for issue of a Certified true copy of Certificate of Competency or of Letter of Authority for Delivery of a Certificate of Competency.

FORM I- Form of Application for Sight Test.

____________________________________________________________________________________________________________

FORM A

Rotation No…………………………
(Official use Only

________________________________

APPLICATION FOR EXAMINATIONS OF MASTERS AND MATES OF FOREIGN GOING AND HOME TRADE SHIPS, SKIPPERS AND SECOND HAND OF FISHING VESSELS.

(1) Grade of Examination ……………………………………….

(2) Place of Examination: Bombay/Calcutta/Madras

(3) (a) Surname __________________________________________

(Block Letters)

(b) Fulle Name ________________________________________

(As on records-Block Letters)

PHOTO

(4) (a) Permanent : _____________________________________

____________________________________

(b) Present Address:__________________________________

___________________________________

(5) Discharge Book No…………………. (6) Nationality……………….

(7) Date of Birth………………………….. (8) Place of Birth…………….

(Proof to be produced)

(9) Height ………………cm (10) Colour of Eyes…………..

Hair…………..

(11) Complexion…………………. (12) Personal Marks……………….

B.(13) Details of Previous Certificate of Competency/Service(if any):-

(a) Grade………………F.G./H.T. (b) Certificate No………………..

(14) Was your Certificate cancelled or suspended by any authority?

Give details.

C.(15) Details of scholastic education and professional training :-

(a) Scholastic Education School/College…………………………

Examination Passed…………………..

Year………………….

(b) Pre-sea training Rajendra/District/Seaman/Indian/

Navy/Others.

whilst at sea as a cadet (2M/MHT only)

(d) Period of attendance at L.B.S. Nautical and

Engineering College prior to first attempt

(certificate to be produced) From………. to……….

_______________________________________________________________________________________________________________________________________________

Take Notice—Any person who makes, procures to be made or assists in making any false representation for the purpose of obtaining for himself or any other person, a Certificate either of Competency or Service is for each offence liable to be punished for cheating under Section 420 of the Indian Penal Code and also for knowingly giving false information to the public servant under Section 182 of the Indian Penal Code.

_______________________________________________________________________________________________________________________________________________

D.(16) Full particulars of Sea Service---

Testimonial

No.

Name of ship

Gross

Tonnage

Port of Registry & O.No.

Trade

HT/FG

Capa-city

From

Period

Remarks

For Office use only :

                                                Particulars                     Total Service at Sea for ________
                                                                                    which proof is now
                                                                                    produced

Certificate No. date

issued

Indentures/Sea Service ------------------- 1.Cadets record book scrutinised

and found/not found to be

satisfactory.

Birth ------------------- 2.Candidate described above is

eligible for Examination for

Certificate of Competency as……………

Competency/Service ------------------ subject to remarks in

Section 'H'

First Aid at Sea ----------------- Examiner.

Life Boat ----------------

Radar of server -----------------

Fire-fighting Course -----------

Radar Simulator Course ------------------

Medical Aid at Sea ------------------

RADIO Telephone ------------------

Operator

_______________________________________________________________________________________________________________________________________________

E.(17) Declaration to be made by the candidate (sea note) :-

"I hereby declare that the particulars contained in Section A,B,C, and D of this form are correct and true to the best of my knowledge and belief and that the pepers enumerated in Section D sent with this form are ture and genuine documents, given and signed by the persons whose names appear on them. I further declare that the statement (D) contains a true and correct account of the whole of my sea service without exception, and I make this declaration conscientiously believing the same to be true"

(--------------------------)

Signature of candidate The above declaration was signed

in my presence.

(---------------------------)

Examiner of Masters and Mates.

Mercantile Marine Department

Bombay/Madras/Calcutta.

_______________________________________________________________________________________________________________________________________________

F.(18) Request for allotment of seat for examination.

Number of

attempts

Month

Fees Paid

Examination

Parts

Signature of candidate with date.

Amount

Date

Recd.

_______________________________________________________________________________________________________________________________________________

(20) Under the provision of rules 63 and 64 this candidate is required to attend course of instructions/to perform further sea service as follows:-

Month

Port

Part of

Examination

Requirement

eligible

Signature of examiner.

Signature of candidate

G.(19) Result of Examination.

Sight	Test		Examination Parts					Remarks signature
Port	Results	Signature	A	B	C	D	E

_______________________________________________________________________________________________________________________________________________

H.(21) Certificate of Examiner:

I hereby certify that ----

(a) The candidate described in Sec. A has produced satisfactory testimonials proofs of sea service/Watchkeeping service.

(b) The candidate complies with the requirement of M.S. (Examination of Masters and Mates) Rules with the exception of the following, he has, however, been permitted to appear for the examination under the provisions of rules______________________________

(i)

(ii)

(iii)

(iv)

(v)

(c) The candidate has passed the examination for the certificate of competency as __________________ and letter of authority/Form Exn. I. No…………………. Date…………….. was issued to him. His certificate of competency may be forwarded to Mercantile Marine Department____________________ for issue: subject to compliance with sub-para (b) of this Section.

Examiner of Masters & Mates

Mercantile Marine Department,

________________ District

_______________________________________________________________________________________________________________________________________________

FORM-B

CERTIFICATE OF WATCHKEEPING

Part 1

This is to certify that Shri ………………………………………. has served on the S.s./M.V. capacity of *(1^st) (2^nd) (3^rd) (4^th ) watchkeeping officer under my command

*During this period Shri …………………………………………………… was an officer in full charge of a watch for not less than ………………….. hours out of every twenty-four whilst the vessel was at sea.

*In addition he has regularly carried out other duties in connection with the routine and maintenance of the ship.

*Bridge watches were doubled during the following Period and at no other times………………………………………………………………………………………………………………………………………………………………………………………………………

During those Periods Shri …………………………………………………. served as the senior/junior of two bridge-Keeping officers. During the periods of engagement stated above Shri ………………………………………………………………………………………………………

**(a) Was granted no Leave of absence

**(b) Was granted Leave of absence from…………….. To……………….

Signature of Master

Date

Part II

May be completed by the company marine superintendent if the master is absent during the Periods stated.

*During the Periods from …………………….. to …………………the vessel was on operational service and Shri ………………………………….. was off articles.

*During the Period from ………………………. to ……………………. the vessel was laid up or undergoing engine repairs and Shri ……………………. was *on/off articles

Signature of *master/superintendent……………………..

Date

*Delete if not applicable

**Delete as appropriate

_______________________________________________________________________________________________________________________________________________

FORM 'C'

CERTIFICATE OF MEDICAL FITNESS FOR AN OFFICER

TO WORK ON BOARD SHIP.

Date of examination : Passport/CDC No:

Name of the Candidate:

Colour of eyes: Hair:

Permanent Address of the Candidate:

Complexion :

Age Height:

Identification marks

Result of the medical examination:

Signature of thumb impression of Officer:

Seal

Place

Date: Signature of the Medical Officer

_______________________________________________________________________________________________________________________________________________

Note:- In case a candidate is declared unfit---reasons for unfitness to be indicated

_______________________________________________________________________________________________________________________________________________

FORM D

Conditional Letter of Authority Conditional Letter of Authority for delivery of

Certificate of Competency

Port __________________________ Port__________________________

Sr.No.________________________ Sr.No._________________________

Date_________________________ Date___________________________

Forwarded to :

To:

Principal Officer. The Principal Officer,
Mercantile Marine Mercantile Marine Department……….District.

Deptt……….

Name ___________________ Shri _______________________described below

_________________________ passed the Navy Limited Examination for the

Grade___________________ certificate of Competency as __________ held

Date of Exam____________ on the _____________ day of _____ 19______ and

(_________________________) the Certificate of Competency forwarded to

Signature of Examiner you by the Chief Examiner may be delivered

Sea Service/Watch-Keeping to him* subject to his producing adequate proof for the following :

(a) Sea service/Watch keeping service of _______ months

(b) Additional Certificates: (i)___________

(ii)__________

(iii)__________

Service___________________

Additional Certificates:

(i)_________________________

(ii)_________________________ Signature of Examiner

(iii)_________________________ (Seal)

Colour of Eyes_______________ Name of Candidate__________________________

Colour of Hair_______________ Grade for which passed________ Roll No.______

Personal Marks_____________ Height___cms. Colour of (i) Eye____ (ii) Hair___

(__________________________) Complexion__________ Personal Marks_______

Signature of the candidate

NOTE :- *Proof of sea-Service/Additional Certificates shall be entered on the application form and the same returned to the Chief Examiner.

This letter of authority does not have the effect of a Certificate of Competency.

_______________________________________________________________________________________________________________________________________________

FORM E

Rotation No…………………………
(Official use Only

________________________________

NAVY LIMITED EXAMINATION

APPLICATION FOR EXAMINATIONS OF MASTERS AND MATES OF FOREIGN-GOING AND HOME TRADE SHIPS

(1) Grade of Examination ……………………………………….

(2) Place of Examination: Bombay/Calcutta/Madras

(3) (a) Surname __________________________________________

(Block Letters)

(b) Fulle Name ________________________________________

(As on records-Block Letters)

PHOTO

(4) (a) Permanent : _____________________________________

_________________________________

(b) Present Address:__________________________________

___________________________________

(5) Discharge Book No…………………. (6) Nationality……………….

(7) Date of Birth………………………….. (8) Place of Birth…………….

(Proof to be produced)

(9) Height ………………cm (10) Colour of Eyes…………..

Hair…………..

(11) Complexion…………………. (12) Personal Marks……………….

B.(13) Details of Previous Certificate of Competency/Service(if any):-

(a) Grade………………F.G./H.T. (b) Certificate No………………..

(14) Was your Certificate cancelled or suspended by any authority?

Give details.

………………………………………………………………………………….

C.(15) Details of scholastic education and professional training :-

(a) Scholastic Education School/College…………………………

Examination Passed…………………..

Year………………….

(b) National Defence Academy Year……………………………

(Certificate to be produced)

______________________________________________________________________________

(i)

______________________________________________________________________________

(ii)

______________________________________________________________________________

(iii)

______________________________________________________________________________

D.(16) Full particulars of Sea Service---

Testimonial

No.

Name of Naval Establishment

Rank

Sea-going or Shore

Nature of duties

From

Period

Remarks

______________________________________________________________________________

For office use only :--

Particulars

Certificate No. Date issued Total Sea Service

Birth Naval ships……………

Leave (--)

Repair or laid up (--)

Watch-Keeping Period.

(Total Nos.)

Competency/Service

Total Qualifying Service

First Aid At Sea

Life Boat

Radar observer Candidate described above is eligible to appear

for Examination for

Certificate of Competency as……………………

Fire-fighting Course

Radar Simulstor Course

Medical Aid at Sea Examiner.

E.(17) Declaration to be made by the candidate (see note 1) :--

"I hereby declare that the particulars contained in Section A,B,C, and D of this form are correct and true to the best of my knowledge and belief and that the papers enumerated in section D and sent with this form are true and genuine documents, given and signed by the persons whose name appear on them. I further declare that the statement (D) contains a true and correct account of the whole of my sea service without exception and I make this declaration conscientiously believing the same to be true."

(__________________________)

Signature of candidate

The above declaration was

signed in my presence

Examiner of Masters and Mates,

Mercantile Marine Department,

Bombay/Madras/Calcutta

18.(1) Certificate by Chief of Naval Staff

I hereby certify that the particulars contained in this application form are correct and show a correct receipt of the whole of the officer's service in the Indian Navy. During the period of service on naval ships the above described officer was granted leave for a total period of ___________ years ________ months ________ days. From the records maintained the N.H.Q. the total period which cannot be considered as sea-service on account of the ships being laid up under repairs or in dry-docks is _____________ years __________ months _______ days.

Training particulars mentioned in Div. 'C' are correct and it is certified that the candidate's attendance and performance at the I.N.S. Vendurthy was regular and satisfactory.

It is further certified that the above officer was engaged on deck and navigational watch duties during the whole of the service mentioned above and the said officer was granted a full naval watch-keeping certification_____________

This officer is a Special Duty Officer in ____________ Branch of the Indian Navy and he has/has not obtained the full naval watch-keeping certificate.

Signature___________________

Chief Of Naval Staff

Indian Navy

(19) Request for allotment of seat for examination.

Number of

attempts

Month

Fees Paid

Examination

Parts

Signature of candidate with date.

Amount

Date

Recd.

_____________________________________________________________________________

(20) Under the provision of rules 63 and 64 this candidate is required to attend course of instructions/to perform further sea service as follows:-

Month

Port

Part of

Examination

Requirement

eligible

Signature of examiner.

Signature of candidate

21 Result of Examination.

Sight Test		Examination Parts						Remarks	Signature
Port Date	Results	Sig.	A	B	C	D	E

(22) Certificate of Examiner:

I hereby certify that ----

(a) The candidate described in Sec. A has produced satisfactory testimonials proofs of sea service/Watchkeeping service.

(i)

(ii)

(iii)

(iv)

(v)

(c) The candidate has passed the examination for the certificate of competency as __________________ and letter of authority/Form Exn. I. No…………………. Date…………….. was issued to him. His certificate of competency may be forwarded to Mercantile Marine Department____________________ for issue: subject to compliance with sub-para (b) of this Section.

Examiner of Masters & Mates

Mercantile Marine Department,

________________ District

_______________________________________________________________________________________________________________________________________________

FORM -F

Letter of Authority Letter of Authority for delivery of

the Certificate of Competency

Port __________________________ Port__________________________

Sr.No.________________________ Sr.No._________________________

Date_________________________ Date___________________________

Forwarded to :

To:

Principal Officer. The Principal Officer,

Mercantile Marine Mercantile Marine Department……….District.

Deptt……….

Name ___________________ Shri _______________________described below

_________________________ passed the Navy Limited Examination for the

Grade___________________ certificate of Competency as __________ held

Date of Exam____________ on the _____________ day of _____ 19______ and

Signature of the Certificate of Competency forwarded to

Examiner________________ you by the Chief Examiner may be delivered to

Signature of Examiner

(Seal)

Colour of Eyes: Name of Candidate__________________________

Colour of Hair: Grade for which passed________ Rol No.______

Height___cms. Colour of (i)Eyes:________

(ii)Hair:

Personal Marks:____________ Personel Marks:______________________________

____________________________ _____________________________________________

Signature of Candidate_______ Signature of Candidate______________________-

NOTE:- Unless cancelled by or on behalf of the of the Chief Examiner this letter of Competency of the respective grade, properly issued under the Merchant Shipping (Examination of Masters & Mates) Rules 19_____ until such times as a Certificate of Competency is issued.

_______________________________________________________________________________________________________________________________________________

FORM-G

Result of Examination for Result of Examination for Certificate of

Certificate of Competency Competency as _______________________

as______________________ Date :_____________

Port:____________________ Port:__________________

Date:____________________ Ser.No.________________

Sr.No.___________________ (A)Name of Candidate:_________________

(A)Name of Candidate: Rotation No._____ Height:____ cms.

_________________________ Colour of (1)Eyes:______ (2) Hair:____

Rot.No._________________ Date of Birth________ Complexion:___

Height:_____________ cms. Personal Marks:____________________

Colour of (1) Eyes:______

(2) Hair:______

Date of Birth:____________

Complexion:_____________

Personal Marks:_________

__________________________

(B) Sight Test: (B) Sight Test:

Port	Date	Result	Signature		Port	Date	Results	Signature

Result of Examination Result of Examination :

Port

Date

Parts

Month next

eligible

Sig-

nature

of Exa-

miner

Port

Date

Part

Part C

Part

Month

elgible

Signa-ture

_______________________________________________________________________________________________________________________________________________

FORM – H

Application for issue of certified true copy of Certificate of Competency or a Letter of Authority for delivery of a Certificate of Competency.

(A) Full Name:_____________________________________________________________

Date & Place of Birth:__________________________________________________

(B) Details of Certificate of Competency of Letter of Authority of which a certified copy is required :

Grade:_________________________ No.________________________

Date:__________________________

Passed:_______________________ Issued at_______________________

______________________________________________________________________________

Name of ship Port of Registry Official No. Capacity From To Remarks

______________________________________________________________________________

(D)(i) I hereby declare that the particulars contained in section A,B, C and of this form are correct and true to the best of my knowledge and that the Certificate of Competency/Letter of Authority described in Section B was decaced/destroyed/lost under the following circumstances:

(ii) The certified true copy of the Certificate of Competency/Letter of Authority be delivered to me at the Port of ________________________

Signature of Candidate

(E) For Office use only :

(i) The above statement was signed in my presence and it is recommended that the certified true copy of the Certificate of Competency/Letter of Authority described above may be issued.

Principal Officer

Mercantile Marine Department

________________ District.

(ii) Certified copy enclosed. (iii) Certified copy is issued

Appropriate fees *may/ *Fees of ________ Received.

may not be charged.

Chief Examiner Principal Officer

Note: *Delete words that do not apply.

on issue of the duplicate this form shall be returned to the Chief Examiner.

_______________________________________________________________________________________________________________________________________________

FORM-I

Rotation No._________________

(Official use only)

A. (1) Place of Examination____________________________________________

(2) (a) Surname_____________________________________________________

(BLOCK LETTERS)

(b) Full Name____________________________________________________

(As on records-Block letters)

(3) Permanent Address______________________________________________

_________________________________________________________________

(4) Discharge Book No.______________________________________________

(if any)

(5) Nationality______________________________________________________

(6) Date of Birth____________________________________________________

(7) Place of Birth____________________________________________________

(8) Height (cms) ____________________________________________________

(9) Colour of eyes___________________________________________________

/hair

(10) Complexion____________________________________________________

(11) Personal Marks__________________________________________________

(12) Rank (if serving at sea) __________________________________________

(13) If about to go to sea

(a) Name of Company__________________ (b) Capacity______________

(14) (a) Date of previous eye-sight test________________________________

(b) Results : Passed/Failed

Declaration of candidate :

I hereby declare that the particulars stated above are correct and true to the best of my knowledge and belief. I further declare that except as stated in Column 14, I was not examined in an eye-sight test held in any Mercantile Marine Department. I wear/do not wear aids to vision.

Signature of Candidate

The above declaration was signed

in presence of

____________________________

Examiner of Masters & Mates,

Mercantile Marine Department,

__________________ District

B. A fee of Rs.__________________ was Received for examination in Sight Test.

Signature_______________________

Date____________________

Place____________________

C. Examiner's Certificate

I hereby certify that the candidate described above was examined in Sight Test under the provisions of Appendix 'G' of the Merchant Shipping (Examination of Masters & mates) Rules.

The result* of the test were as follows :-

Standard	With or without aids to vision	Form	Colour	Results

(1) He may be examined at any time with aids to vision.

(2) He may be examined after a lapse of one month.

(3) He may not be re-examined again without the prior approval of the Chief Examiner.

Note:- If failed or to be referred for further advice, one copy of this application form shall be forwarded to the Chief Examiner with a detailed report.

Delete if not applicable

Where not examined indicate by stating N.E.

FORM-J

Rotation No.____________________

SIGHT TEST CERTIFICATE

Full Name: ___________________________________________________________________

Date of Birth:_____________________________ Birth Place_____________________

Rank:____________________________________ Height:_________________________

Colour of Eyes:___________________________ Hair:___________________________

Complexion:______________________________ Personal Marks_________________

I hereby certify that the result of Examination is as follows*

______________________________________________________________________________

aids to vision Form Colour Results

______________________________________________________________________________

Standard With/Without

______________________________________________________________________________

New Entry Without

______________________________________________________________________________

1. He may be examined at any time with aids to vision.

2. He may be examined after a lapse of one month.

3. He may be re-examined again without the prior approval of the Chief Examiner.

Date at _______________________ this day of ________________ 19_________________

Examiner's Signature_________________ District______________________

Candidate's Signature___________________________

Note : *Where not examined indicate by stating N.E.

Delete if not applicable.

This certificate is valid for six months from the above date.