PRC-MEO Form No.

5
Rev.01/11-14-2000

Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MARINE DECK OFFICERS

CERTIFICATE OF SEA SERVICE

(All statement herein are subject to verification)

TO THE BOARD OF MARINE ENGINEER OFFICERS:

THIS CERTIFIES that had actually served under our

supervision on board , of
(name of vessel) (type of vessel) (state the Nationality of Vessel)
with Official No.: a vessel of KW and Gross tonnage
(Near coastal/ Seagoing)

for a period of , , from to

(No. of years) (Months) (Days) (Date of Embarkation) (Date of Discharge)
as .
(Position Held)
This certifies further that the above-stated data are all true, any false statement/s made therein shall be a
ground for criminal prosecution.

Issued this day of 20 at .

SEAL OF VESSEL
SEAL OF THE COMPANY

Master: Signature Above Printed Name

Nationality:
Name and Signature of Port Captain / Personnel Mgr. Kind of License:
Registration No:
Date of Registration:
Expiry Date:
Name of Local Ship owner or Manning Agent

Address:
Chief Engineer: Signature Above Printed Name
Nationality:
Telephone Nos. 63- 2-523 88 71 Kind of License:
Registration No:
Date of Registration:
Expiry Date:

SUBSCRIBED AND SWORN TO before me this day of ,20 ,

at .
Doc.No.
Page No.
Book No.
Series of NOTARY PUBLIC

Note: This form is only good for one vessel. This form can be reproduced. All entries must be typewritten Erasures / alteration may be grounds for denial.