Application No.

:_____________ MMD : (MUM / CHN / KOL) Received Date:______________ EXN3-Form 15(A)

APPLICATION FOR REVALIDATION OF CERTIFICATE OF COMPETENCY
FOR ENGINEER OFFICERS Photograph
1. NAME:__________________________________________________________________________
duly attested
by examiner
(As required on CoC as per passport – copy of same to be enclosed)
2. Details of Previous Certificate (Grade):______ No.:_______Date of Issue:________Validity:______
3. D.O.B.:__________ Place of Birth:___________ INDOS No.:____________ CDC No.:__________ PP No:__________

Additional Certificates Number Date of Issue Issuing Authority

Medical Fitness Certificate
Revalidation Course

4. SEA SERVICE FOR THE LAST FIVE YEARS (Attach copy of CDC and service record duly authenticated by employer):
Period
Name of Ship O. No. KW Trade Type of Ship Capacity From To
Y M D

Total Article Period Total QSS

5. Details of service ashore, considered equivalent to service on board sea going ships as Marine Engineer Officer, during the last 5 years
giving period of service, designation, nature of duties, name, address & contact of employer (attached employer Certificate)
____________________________________________________________________________________________________________
6. Did any of the ships mentioned in para 4 suffer any causalities during your service on board? If so, give details of date, time and
nature of casualty.
____________________________________________________________________________________________________________
7. Did you undergo any inquiry by any Government or other Authorities in connection with your service on board ships mentioned in
para 4? If so, give details of date, place, name of Authority and Nature of Inquiry.
____________________________________________________________________________________________________________
8. Was any warning / cautionary notice issued to you by the any appropriate authority due to some incidence / accidents on board ship
duly the last 5 years.
9. A fees Rs.2,500 for Revalidation of Certificate of Competency has been deposited (receipt attached)
10. Three copies of 30 mm x 25 mm size colour photographs.
Details of Upgradation / Revalidation (Attach Certificate)

Name of Certificate Name of Institute Date of Commencement Date of Completion

I hereby declare that the information given above is correct and true to the best of my knowledge and belief.

____________________
Date :_________________ Signature of Applicant.
Note : Any person who makes any false representation or knowingly givens any false information is liable for punishment of cheating
under section 182 and 420 of Indian Penal Code and Certificate of Competency shall be withdrawn forthwith.
_______________________________________________________________________________________________________________
(FOR OFFICE USE ONLY)
The Eligibility of the candidates for issuance of revalidation endorsement was scrutinized in accordance with the guidelines and found to be in order.
* The certificate of competency revalidated until
EXAMINER OF ENGINEERS
Date :____________________ MERCANTILE MARINE DEPARTMENT
MUMBAI / KOLKATA / CHENNAI
CANDIDATE'S SPECIMEN SIGNATURE

Address and Communication Details on reverse

 Requirement for Revalidation of Engineer Officers

1. Certificate of Competency issued under STCW’95 (Respective Grade).

2. Medical fitness certificate as per M.S. (Medical Examination) Rules, 2000.
3. 10 days Revalidation course certificate.
4. Approved sea going service, performing functions appropriate to the certificate held,
for a period of at least one year in total during the preceding five years;
OR
Having performed functions considered to be equivalent to the seagoing service (e.g. officers
working in marine related jobs, such as maritime surveyors, lecturers, technical
superintendents, etc.)
OR
Having completed approved seagoing service, performing functions appropriate to the
certificate held, for a period of not less than three months in a supernumerary capacity, or in a
lower officer rank than that for which the certificate held in valid immediately prior to taking
up the rank for which it is valid.

5. Duly filled application form along with fees of Rs.2,500/- to be submitted at MMD.
6. C.D.C.
7. Passport.
8. Three copies of 30 mm x 25 mm size colour photographs.
9. Address and Communication details :
Address :

Tel. No.: Mobile No. Fax No.

Email ID :