Safety Certificate Verification

mm/dd/yyyy
Name: ____________________; Date of Birth: ; Passport: ________________

Please complete this form indicating original STCW certificates that you hold. Please use:
month/day/year when filling in expiration dates.

N/A: I do not hold any STCW certificates.

Personal Survival Techniques A-VI/1-1; Expiration Date: ____________

Fire Prevention & Fire Fighting, A-VI/1-2; Expiration Date: ____________

Elementary First Aid, A-VI/1-3; Expiration Date: ____________

Personal Safety & Social Responsibilities, A-VI/1-4; Expiration Date: ____________

Proficiency in Survival Craft and Rescue Boats

other than Fast Rescue Boats, A-VI/2-1; Expiration Date: ____________

Proficiency in Fast Rescue Boats, A-VI/2-2; Expiration Date: ____________

Advanced Fire Fighting A-VI/3; Expiration Date: ____________

Medical First Aid, A-VI/4-1; Expiration Date: ____________

Medical Care Onboard Ship, A-VI/4-2; Expiration Date: ____________

Ship Security Officer, A-VI/5; Expiration Date: ____________

Security Awareness, A-VI/6-1; Expiration Date: ____________

Designated Security Duties, A-VI/6-2; Expiration Date: ____________

Crowd Management, A-V/2 or A-V/3; Expiration Date: ____________

Crisis Management & Human Behavior, A-V/2 or A-V/3; Expiration Date: ____________

Marine & Technical Only:

Ratings Navigational Watch, A-II/4; Expiration Date: ____________

Ratings Engineering Watch, A-III/4; Expiration Date: ____________

Required:

Yes No I have 12 months sea time during the past 5 years. If yes,
please indicate sea service on DCL application form.
*Please note: Crew Member must carry original STCW certificates when embarking the ship.

The attached are authentic copies.

_____________________ _________________________ mm/dd/yyyy

_______________
Printed Name Signature Date
29 July 2015