ADD NO.

:
Initial Issue Date: 10-07-2016
Revision Date: 00

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF TRANSPORTATION

MARITIME INDUSTRY AUTHORITY

STCW OFFICE
FORM 3: QUALIFICATION OF SUPERVISORS, INSTRUCTORS
AND ASSESSORS
(Individual information sheet to be attached)

Training in
License / Simulator-based
Subject Highest IMO Model
Certificate Training
Name Position taught / educational Course
of Certificate
Assessed Attainment 6.09
Proficiency (if applicable)
and/or 3.12

NEW &
Master 6.09
Dela Peña, Nhe P. Instructor UPDATING MLC BSMT None
Mariner
FOR DECK

NEW &
Fernandez, Renato Instructor Master 6.09
UPDATING MLC BSMT 6.10
E. / Assessor Mariner 3.12
FOR DECK

NEW &
Macatangay, Instructor Master 6.09
UPDATING MLC BSMT 6.10
Edison F. / Assessor Mariner 3.12
FOR DECK

NEW &
Instructor Master 6.09
Marquez, Jose L. III UPDATING MLC BSMT 6.10
/ Assessor Mariner 3.12
FOR DECK

NEW &
Rosales, Miguel Instructor Master 6.09
UPDATING MLC BSMT 6.10
Ricardo U. / Assessor Mariner 3.12
FOR DECK

NEW &
Echavez, Vicente S. Instructor Master 6.09
UPDATING MLC BSMT 6.10
Jr. / Assessor Mariner 3.12
FOR DECK

Asst.
Vasquez, 6.09
Training SUPERVISOR AMAR.E N/A None
Emmanuel Z. 3.12
Manager

(To be accomplished by the STCW Office)

Evaluator’s Comment

_________________________________
Evaluator’s Signature over Printed Name

___________________________________
Date Evaluated