Form “C”

NATIONAL TELECOMMUNICATIONS COMMISSION
Radio Regulations and Licensing Department RADIO OPERATOR AND TRAINING SCHOOL DIVISION BIR Road, East Triangle, Diliman, Quezon City

Application for NEW/RENEWAL/REVALIDATION Of STCW Certificates  
Date: NAME: Family Name Mailing/Home Address: Telephone Nos. Height: Weight: Place and date of examination: I HEREBY CERTIFY that I have read and understood the instruction and attached the requirements as stated in this application form. Date of Birth Place of Birth: Given Name Middle Name.

 GOC – Certificate of Competency (COC)  REC – Certificate of Endorsement (COE)

Signature over printed name EVALUATOR CRS Verification CASHIER

REQUIREMENTS TO BE SUBMITTED:
** All applicants for the issuance of GMDSS Certificate must be medically fit and should be with good eyesight and hearing. The latest medical Certificate using the DOH approved seafarers pre-employment medical form must be submitted together with the application for issuance of GMDSS Certificate. New (ROC/GOC) 1. Original copy of the Result of Rating of Examination 2. Duly accomplished application form (form C) 3. Duly accomplished (notarized) information sheet (form D) 4. Four (4) identical copies 1” X 1” ID picture 5. Documentary Stamp Renewal (ROC/GOC) 1. Original copy of the Certificate to be renewed 2. Duly accomplished application form (form C) 3. Four (4) identical copies 1” X 1” ID picture 4. Certificate of Sea Service (Employment or Copy of SIRB) performing functions appropriate to the license held for a period of at least one (1) year in total for the preceding five (5) years. 5. Documentary stamp Renewal (REC) 1. Original copy of Certificate to be renewed. 2. Duly accomplished application form (form C). 3. Copy of valid Radio Operator’s Certificates (GOC/1RTG). 4. Four (4) identical copies 1” X 1” ID picture. Documentary stamp 6. Certificate of Sea Service (Employment or Copy of SIRB) performing functions appropriate to the license held for a period of at least one (1) year in total for the preceding five (5) years.

New (REC) 1. Original copy of the Result of Rating of Examination. 2. Duly accomplished application form (form C). 3. Copy of valid Radio Operator’s Certificates (GOC/1RTG). 4. Three (4) identical copies 1” X 1” ID picture. 5. Documentary stamp

Revalidation 1. Original copy of STCW Certificate to be revalidated 2. Copy of Certificate of Completion of refresher course 3. Accomplished application form (form C) 4. Four (4) identical copies 1” X 1” ID picture 5. Copy of valid Radio Operator’s Certificates (GOC/1RTG) – for REC 6. Documentary stamp FEES PER YEAR GOC P180.00 ROC P180.00 REC P380.00

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