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MPA FORMC.28

Rank Applied For Recommended By Relationship to seafarer Date of Application

NAME Nationality Height Weight Body

Mass

Date of Birth / Age

*

Place of Birth Blood Group Overall Size Safety Shoe Size Sex Religion No. of

Dependents

Seafarer's Permanent Address Next of Kin, Relationship and Address Alternative Next of Kin, Relation

Tel. No.(HOME)

Mobile

Document Number Issued by Date of Issue Date o

Seafarer's Passport

VISA - USA (Please circle : Type B / C1 / D)

Seaman's Discharge Book

Medical Fitness Certificate ( as per STCW / FLAG STATE )

STCW95 & Flag State Doucments STCW Regulation No. Number Issued by Date of Issue Date o

Officers' Certificate of Competency -COC

Electro Technical Officer ( S TCW 2010 ) A-III/6

Singapore Certificate or Endorsement - COE

Panama Licence / Seaman's Discharge Book

Malaysia Certificate of Recognition

Malaysia Seaman's Identification

STCW Endorsement for Officers

STCW Watchkeeping Certificate for Ratings

STCW Special Training (V/1. V/2)

STCW Familiarisation Training

STCW Personal Survival Techniques -PST A-VI/1-1

STCW Fire Prevention and Fire Fighting - FPF A-VI/1-2

STCW Elementary First Aid - EFA A-VI/1-3

STCW Personal Safety & Social Resp.-PSSR A-VI/1-4

STCW Prof in Survival Craft / lifeboat - PSCRB A-VI/2

STCW Prof in Fast Rescue Boats - FRB

STCW Advanced Fire Fighting - AFF A-VI/3

STCW Medical First Aid -MFA A-VI/4-2

STCW Medical care on board ( Ship Captain ) A-VI/4-1

GMDSS General Operator's Certificate A-IV/2

GMDSS Restricted Operator's Certificate IV/2

Designated Security Duties ( STCW 2010 ) A-VI/6-2

Security Awareness ( STCW 2010 ) A-VI/6-1

ECDIS ( STCW 2010 )

Able Seafarer Certificate ( STCW 2010 )

A-VI/5

Cook's Training Certificate ( MLC, 2006 )

Ship Security Officer - SSO

International Passport

(PHO

Seafarer's Employment Application Form cum Checklist

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