Republic of the Philippines

OFFICE OF THE PRESIDENT

COMMISION OF HIGHER EDUCATION

DEPARTMENT OF TRANSPORTATION
MARITIME INDUSTRY AUTHORITY

CERTIFICATE OF SEA SERVICE

Sir/ Madam:

This is to certify that ____________ holder of SIRB No. ____ has

been employed by this company with the following sea going service/s:

Name Route Period Covered

IMO No./ Total Sea
of Type Official
(Foreign Gross KW From To Position/
Service
Registry
I Tonnage Power Y/M/D Y/M/D Rank
Vessel No. Y-M-D
Domestic

This further certifies that the above-stated data are true and that any false statemen/
t s made
herein shall be ground for criminal prosecution.

Issued this ______ day of ______ at _____ ___

COMPANY SEAL
President / Duly Authorized Person
Signature above Printed Name

Note:
This form is good for only for one (1) vessel. This form can be reproduced. Any erasure/obliteration may be a
ground for denial.