MSF 4275 / REV 0607

APPLICATION FOR AN ORAL EXAMINATION LEADING TO THE ISSUE OF A CERTIFICATE OF COMPETENCY (STCW 95) FOR Engineer Officers in the Merchant Navy

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IMPORTANT - BEFORE completing this form, please ensure you have read fully the guidance notes and instructions on pages 5 and 6. Please note your unique form number if you wish to check the status of your application online. 1 PERSONAL DETAILS
Title Mr/Mrs/Miss/Capt etc Surname / Family name / Last name Forename(s) in full Date of Birth Place of Birth Nationality Country of Birth National Identity No. Address for return of documents (if different from home address) FORM NUMBER Sex: Male / Female

Full Home Address Address

District Town / City County / State Post Code / Zip Country Telephone No. Mobile No. Email

2 CERTIFICATE APPLIED FOR

Capacity OOW Engineer Second Engineer Second Engineer Second Engineer Chief Engineer Chief Engineer Chief Engineer Marine Engine Operator Licence Senior Marine Engine Operator Licence STCW Reference III/1 III/2 III/3 III/3 III/3 III/2 III/2 Power Limits kW Unlimited Unlimited Less than 3000 Less than 3000 Less than 3000 Less than 6000 Unlimited Area Limitation Steam / Motor / Combined None None None Near Coastal None Near Coastal None Please tick

Please do not write below this line

Received: Fee:
SDS No Receipt No Efin No Application ID NoE ID Form Number

CoC No

3 SEA SERVICE

- take details from your Discharge Book and / or Certificates of Discharge

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Engineer Officers- this means service on crew agreement as an Engineer Officer on regular watch over the main propelling machinery or auxiliary machinery, or duty engineer on ships with unattended machinery spaces or day work. This must be supported by testimonials signed by the Chief Engineer, Engineer Superintendent or Master as appropriate. ALL RELEVANT SEA SERVICE MUST BE LISTED. If there is insufficient space, please continue on a separate sheet. Sea service on foreign flag ships will be accepted under the same conditions as service on UK ships provided it can be properly verified. LENGTH OF VOYAGE: this must be given in calendar months and days, eg from 3 January to 5 March = 2 months and 3 days. Odd days should be added together and reckoned at 30 days to the month. SHIP AND VOYAGE DETAILS
Vessel Name IMO Number Flag Reg. Power (kW) S/M Type Rank / Capacity From

DATES
To

DURATION
Months Days

Total S/M Type S = Steam, or M = Motor 1 = Regular watch in the machinery spaces OR unmanned machinery spaces (U.M.S.) Duty Engineer 2 = Other

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4 CHECKLIST
Before a Certificate of Competency can be issued, you will need to submit the following documentation - Original Documents MUST be supplied

If you already hold a Certificate of Competency or Certificate of Service you must send it in with this application and give the following details below Certificate No: Capacity: Country of Issue: (Qualification Conditions Met) Date:

Enter your (Scottish Qualifications Authority) Registration Number:

tick if enclosed

Official Use Only

4A FOR ALL APPLICATIONS

Birth Certificate OR Passport Discharge Book OR Certificates of Discharge Sea Service Testimonials Two Passport Size Photographs (IMPORTANT See Guidance Notes) Valid Medical Fitness Certificate (ENG 1)* * To comply with health and safety requirements in accordance with the Merchant Shipping Training & Certification (Medical Examination) Regulations 2002 and STCW Regulation I/9, any seafarer employed or engaged in any capacity aboard a seagoing vessel must hold a valid medical fitness certificate attesting to their medical fitness for the work for which they are employed. Further information may be obtained from the MCA.

4B APPLICATIONS FOR A FIRST CERTIFICATE

MNTB Workshop Skills Certificate Letter of Initial Assessment or Proof of MNTB Approved Cadetship * Advanced Fire Fighting Certificate Certificate No.

Certificate of Proficiency in Survival Craft, OR Proficiency in Survival Craft & Rescue Boats Valid First Aid at Sea, OR Proficiency in Medical First Aid Certificate OR Proficiency in Medical Care VQ completion certificate MCA letter of initial assessment, IAMI written exam certificate / VQ completion certificate Evidence of engineering skills training If applicable ISF Training Record Book or VQ Course Attendance Letter * UK academic qualifications (if claiming exemptions) * Must be submitted prior to issue of notice of eligibility.

4C APPLICATIONS FOR A SUBSEQUENT CERTIFICATE

VQ Completion Certificate OR UK academic qualifications (if claiming exemptions) IAMI Assessment Certificate OR MCA Letter of assessment OR MCA/SQA written exam certificate(s) If this is your first STCW95 certificate Certificate of Proficiency in Survival Craft, OR Proficiency in Survival Craft & Rescue Boats

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5 YOUR SIGNATURE AND DECLARATION
(The maximum penalty for a false declaration is 5000)
I declare that the data contained in this application is, to the best of my knowledge, true and complete. I also declare that the documents are genuine, given and signed by the persons whose names appear on them. I consent to any processing of the data contained in this application by the MCA (including any processing necessary to establish the authenticity and validity of the issued certificate).

Please sign this form in the centre of the space opposite, in BALL POINT PEN, which will be transferred to your new STCW95 Certificate for office use only

Date..................................................... IMPORTANT - KEEP WITHIN BORDER FAILURE TO COMPLY WITH THIS INSTRUCTION WILL INVALIDATE THE APPLICATION

6 COUNTER SIGNATURE
Name Address

Town / City Country / State Postcode/ Zip Code Telephone No. Capacity in which you know the applicant
I declare that the information given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are, to the best of my knowledge, genuine and relate to the person(s) whose names appear on them. I confirm that the photographs submitted bear a true current likeness of the applicant. Signature.............................................,................................................................Date................................................................................................

Country Occupation

7 PAYMENT
Please enclose the appropriate fee (as laid down in the current Merchant Shipping Fees Regulations). Payment should be made in sterling by cheque, postal order or banker's order, credit or debit card. Cheques, Postal Orders and Bankers Drafts should be made payable to the Maritime and Coastguard Agency and crossed Account Payee and not negotiable. Cheques and orders should be drawn at a UK bank. CASH WILL NOT BE ACCEPTED.

Please tick ( Maestro

) the appropriate box below to indicate your chosen method of payment. Visa Mastercard/Access Delta Cheque/Bankers Draft Postal Orders

Please charge my Maestro / Visa / Mastercard/Access / Delta Card .

Name of Card Holder Card Number (16-18 digits) Start Date Expiry Date Maestro Issue Number (Maestro Cards only) Security Code: The Security Code is the last three digits of the numbers on the reverse of the card, near to the signature strip

Signature...............................................................................................Date..................................................................

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GUIDANCE NOTES FOR THE COMPLETION OF THIS APPLICATION FORM
PLEASE ENSURE THAT YOU READ AND UNDERSTAND THESE NOTES BEFORE COMPLETING THE FORM
Please complete this form in BLOCK LETTERS and in black ink. If a section is not relevant to your application enter NIL. ENSURE YOU COMPLETE THIS FORM IN FULL - FAILURE TO DO SO MAY MEAN WE WILL HAVE TO RETURN YOUR APPLICATION TO YOU, AND WILL RESULT IN A DELAY TO YOUR APPLICATION BEING PROCESSED. Enclose all documents necessary to establish your eligibility for examination for an STCW 95 Certificate of Competency. You must send in ORIGINAL documents, photocopies will NOT be accepted. A document checklist is on page 3 to help you. If eligible you will be issued with a Notice of Eligibility enabling you to sit your written exams and the MCA oral examination. The Notice of Eligibility will advise you how to apply for an appointment for the examination and what you should do once you have taken the examination. A series of Training and Certification Guidance Notes, giving further details of requirements, is available from:- Mail Marketing (Scotland), Bloomsgrove Industrial Estate, Norton Street, Nottingham, NG7 3JG, United Kingdom, TEL: 0155 901 3336, FAX: 0115 901 3334, or on our website - www.mcga.gov.uk

1 PERSONAL DETAILS
Enter your personal details in the boxes provided. Your name should be given IN FULL, and should be given in the same format as appears in your passport or other national identity document. Your date of birth should be given in the format DD/MM/YYYY, eg 18 February 1960 would be written 18/02/1960. National Identity Number should be that in your Passport or Discharge Book. You should give your permanent home address, where you are normally resident. You may also provide an alternative address for return of documents or correspondence relating to this application, eg if you are away at College. Your documents will be returned by courier and will need to be signed for. Please ensure you provide us with the full address details you would like your documents sent to and include a contact telephone should there be any queries with your delivery.

2 CERTIFICATE APPLIED FOR

Please tick the capacity / limitations for which you are applying. Only tick ONE box.

3 SEA SERVICE
Sea Service must be supported by Discharge Book entries, testimonials, and where appropriate, Watch Keeping Certificates. Testimonials must be signed by the Chief Engineer or Master, or in exceptional circumstances by the Engineering Superindendent responsible for the vessel.

4 CHECKLIST
Before a United Kingdom Certificate of Competency can be issued, you will need to submit certain documentation as specified in this section. ORIGINAL documents MUST be supplied, copies will not be accepted. All the documentation indicated in section 4 must be supplied. Documentation listed in Section 4A MUST be supplied BEFORE the Notice of Eligibility can be issued if appropriate. Other documentation can be supplied either before the Notice of Eligibility is issue, OR after the oral examination has been passed, prior to the issue of the Certificate of Competency. PHOTOGRAPHS - Your photographs must be taken full face without a hat and must be passport approved photographs, measuring a maximum of 50mm x 40mm, colour with a white/pale background. The back of one photograph must include your name in BLOCK LETTERS and the signature of a Doctor, Bank Officer, Established Civil Servant, School Teacher or someone of similar standing. They should also write on the back of the photograph "I certify that this is a true likeness of Mr/Mrs/Miss/Ms/Dr etc... " and add their signature. They must also provide their details at Section 6. The person who certifies your photographs must either be a British citizen or a citizen of a Commonwealth country. A member of your family is not allowed to counter sign your photograph. The back of the other photograph must include your name in BLOCK LETTERS and your date of birth. 4B - APPLICATIONS FOR A FIRST CERTIFICATE - documents in this section may be provided with this application, OR when returning the Notice of Eligibility and applying for the Certificate of Competency. Please ensure you tick ( ) the relevant boxes to indicate which documents you have enclosed with this application. 4C - APPLICATIONS FOR A SUBSEQUENT CERTIFICATE - documents in this section may be provided with this application, OR when returning the Notice of Eligibility and applying for the Certificate of Competency. Please ensure you tick ( ) the relevant boxes to indicate which documents you have enclosed with this application. 4D - YOUR SIGNATURE - please sign your usual signature. Ensure that the whole of your signature is contained within the outline of the box - this will be transferred to your new Certificate of Competency.

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5 YOUR SIGNATURE AND DECLARATION
Please read the declaration. Once you are sure that the information you have given is, to the best of your knowledge, true and complete, and that the documents submitted are genuine, given and signed by the persons whose names appear on them, you should sign the declaration with your usual signature, including the date.

6 COUNTER SIGNATURE
You should obtain a counter signature from a responsible person who is NOT related to you and has known you for at least 2 years. They should enter their details in this section. This person must endorse the rear of one of your passport style photographs " I confirm that this is a true current likeness of [ your name], and add their usual signature and date. See also guidance note 4 on Photographs

7 PAYMENT
You must enclose the appropriate fee with your application. The published fee includes worldwide postage. Please tick the appropriate box to indicate your chosen method of payment. Payment must be made in Pounds Sterling (). Payment by cheque, bankers draft or postal orders should be made payable to "The Maritime and Coastguard Agency" and crossed "account payee" and "not negotiable". For payment by Maestro, Visa, Access/Mastercard or Delta, ensure you enter the card details in the spaces provided. Please sign to confirm the amount and chosen method of payment.

NOW RETURN YOUR COMPLETED APPLICATION TO:Seafarer Training and Certification Maritime and Coastguard Agency Spring Place 105 Commercial Road Southampton SO15 1EG Tel +44 (0) 23 8032 9231 Fax +44 (0) 23 8032 9252 e-mail: [email protected]

Completed forms must not be emailed to the MCA. Please post them with the required documentation.

YOU SHOULD ALLOW 28 DAYS FOR US TO PROCESS YOUR APPLICATION

8 APPLICATION TRACKING
You can now track the progress of your application on the MCA website at: www.mcga.gov.uk . Ensure you have made a note of your Form Number (found on Page 1), as this will be required to check your application.

Please do NOT write or mark below this line 9 OFFICIAL USE ONLY
Approved for issue of Notice of Eligibility Yes No Reasons for Rejection

Name Signed Date

Certificate

Date of Issue

QCM Date

Issuing Officer's Signature

Dangerous Cargo Endorsement

Oil

Gas

Chemical