PRC-MDO Form no. 5 (Rev.

00/10/29/98)

NOT FOR SALE
Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION
Manila

BOARD OF MARINE DECK OFFICERS

CERTIFICATE OF SEA SERVICE
(All Statements herein are subject to verification)

TO THE BOARD OF MARINE DECK OFFICERS:
THIS CERTIFIES that (Name of Vessel) of (Steam or Motor) Registry No.: a (Coastwise/Foreign) of gross tons for a period of (No. of years) from (Date of Embarkation) to (Date of Discharge) as (Position Held) (Months) (Days) . . (State the Nationality of the Vessel) vessel with . .

actually served under our supervision on board

This certifies further that the above-stated data are all true and that any false statements made therein shall be a ground for criminal prosecution. Issued at this day of , 20 .

SEAL OF VESSEL

___________________________
SEAL OF COMPANY Master- Signature Above Printed Name Nationality : _______________ Kind of License : _______________ Registration No. : _______________ Date of Registration : _______________ Expiry Date : _______________

________________________________. Name & Signature of Port Captain/Personnel Manager
___________________________________________. Name of Local Shipowner or Manning Agent Address: ____________________________________. ____________________________________________ . Telephone Nos. _______________________________.
Note: This form is good only for one vessel. This form can be reproduced. All entries must be type written. Any erasures/ obliterations may be grounds for denial.