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IMCA Life Support Technician Certification Scheme

Examination Application – Life Support Technician
This form must be completed in full by the sponsoring company (i.e. the candidate’s current or most recent employer), signed by
that company’s nominated authorised signatory and sent directly to the IMCA Certification Schemes Administrator. All specified
attachments must be enclosed with the form and it shall be understood that additional documentation may sometimes be
requested.
The current fee is £150 per compulsory module plus £25 per optional module.
Three passport-sized photographs of the applicant will be required before a certificate is issued.

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Applicant Details:
Surname:

.............................................................................................................................................................

Forename(s):

.............................................................................................................................................................

Address:

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

E-mail address:

............................................................................................................................................... (optional)

2a To be completed for holders of IMCA-recognised bell diver certificates (see IMCA D 04/05)
Diver training certificate number:

................................................................................................................

Issuing authority:

................................................................................................................

Please attach a photocopy of the diver training certificate

Number of years commercial diving experience:

...................................................................

Number of years bell diving experience:

...................................................................

Panel hours logged working as an Assistant LST:

...................................................................

Please attach photocopies of logbook entries for the past two years

Examination Application Form – Life Support Technician (updated December 2006)

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....... If the date of first appointment is more than two years ago....................................................................................................................................... Name: ....................... Training course place: ... British  Norwegian For completion by the company’s Nominated Authorised Signatory (i....................................................... Company name and stamp: ........... Manurewa........................................................................................................................... Aberdeenshire... UK Examination Application Form – Life Support Technician (updated December 2006) Page 2 of 2 .............. Certification Schemes Administrator IMCA.................................................... Safety Manager or person of similar or higher standing within the company) I confirm that I have personally seen the applicant’s logbook(s) and the originals of the attached documents and that I can verify that the information set out above is correct............................ AB51 0XA....... (name) is a suitable candidate for Life Support Technician Signed: ............................................ ............................ I recommend that: ............................................ .................... Midmill...................................................................................................... Address: .............. On the basis of satisfactory offshore reports..................................................................................................... confirming competence in accordance with IMCA guidance on competence assurance and assessment..................................... Date: ..................................... Position: ............................................................. Please attach a photocopy of the assistant life support technician course completion certificate Date of first appointment (following course): ............................... Kintore...................................................... Panel hours logged as an Assistant LST : 3 Optional Legislation Modules Applied For  4 ............................................. please also attach copies of logbook entries for the past two years................................................. Completed application forms should be submitted to: Mrs Vicki Graham................e........................................................................ Please attach photocopies of all letters of appointment............................2b To be completed for all other applicants Assistant LST training course date: ..................................................................................

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