The requirements for the REPLACEMENT CDC are aa)- Form-B completed with photograph for 'REPLACEMENT' o l!

" ##)- $ pa%%port %i&ed photographs '(")cm% * (")cm%) i white shirt+ o a gra!i%h #ac,gro- d additio al to the o e affi*ed to the form" 'total no. of photographs = 3 . e for the form a d the other $ %eparate) 'Name to be written on the re erse of the photos)" cc)- !ne self"a##resse# Post Car# with Rs 3$" postage stamp fi*ed" dd)- !ne self"a##resse# en elope %&' ( )*'+ with Rs. ,-$" postage stamp affi(e# to forward the CDC #! regd po%t with Ac, owledgeme t" ee)- A$C Pa.ee #eman# #raft for Rs )---$- 'for REPLACEMENT CDC%) %/raft from a nationalise# ban0+ ff)- !riginal C/C. gg)- / %et of atteste# cop! of all CDC page%" hh)- A notarise# cop! of !o-r CoC ii)- 'Certificate of Emplo!me t'" - this is not require# - thi% i% o l! re0-ired for people who ha1e ot %ailed for o1er a !ear a d %ome - #a%icall! the! do ot wa t to #e re ewi g CDc% for people who are - li,el! to %ail agai a d therefore i the ca%e of tho%e who ha1e ot %ailed i a while the! ha1e to ha1e proof of a offer of emplo!me t" Please sen# the require# #o1s b. 2PEE/ P!2T " #o not use a 1ourier3 it will be returne# an# registere# post is not absolutel. require#.

4orm " 5 6!7ERNMENT !4 8N/8A

M8N82TR9 !4 2:8PP8N6 APPL8CAT8!N 4!RM 4!R RENE;AL $ REPLACEMENT $ /<PL8CATE
C!NT8N<!<2 /82C:AR6E CERT848CATE"C<M"2EA4ARER=2 8/ENT8T9 /!C<MENT %C/C+
REA/ 8N2TR<CT8!N2 CARE4<LL9 5E4!RE 48LL8N6 <P T:E APPL8CAT8!N 4!RM.

4!R !448CE <2E !NL9

File No2 3333333333333333333333333333333 Remar,%233333333333333333333333333333333 Name/Designation/signature of D.A.____________________Officer ________________ T! 5E 48LLE/ 59 T:E APPL8CANT All the 1olumns are to be fille# neatl. in 5L!C> LETTER2 %<se onl. A? si@e paper for the format an# en1losures+. 5AN> /RA4T NoA 3333333333333333/ate#A 33333333333333 Amount ABBBBBBBBBBBBBBBBBBBB 5an0 BBBBBBBBBBBBBBBBBBBBB
/2" Name of the 1an#i#ate %as entere# in C/C Certifi1ate +

Affi( here a re1ent Passport si@e %3.& Cm ( 3.& Cm+ Photograph of the appli1ant in white shirt

5ran1hABBBBBBBBBBBBBBBB

)+ RENE;AL !4 C/C %N! 4EE2 T! 5E PA8/ 4!R RENE;AL !4 C/C+ Renewal Certifi1ate will be gi en in the form of sti10er3 whi1h the C/C hol#er ma. affi( on CA##itional page for offi1e useC in C/C. !riginal C/C is N!T to be forwar#e# to the 2hipping Master. Atteste# (ero( 1op. of C/C ma. onl. be forwar#e#. /etails of C/CA C/C No 8ssue# at /ate of issue 8ssue# b.

*+ /<PL8CATE C/C
No -ref- da#le fee of Rs.)3---$" %Rupees !ne Thousan# onl.+ for D-plicate CDC%+ to #e paid thro-gh Dema d Draft draw from a ! atio ali&ed #a ,+ i fa1o-r of co cer ed 4hippi g Ma%ter+ pa!a#le at M-m#ai56ol,ata5Che ai + to #e e clo%ed" .rigi al m-tilated 5 tor 5 damaged CDC i% to #e e clo%ed

* /etails of C/C C/C No 8ssue# at /ate of issue 8ssue# b.

48R NoA BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB/ate#BBBBBBBBBBBBBBBBBBBBBBBBBBBBB %!nl. for #upli1ate C/C in 1ase of loss of original C/C+ 3+ REPLACEMENT C/C. % APPL8CA5LE !NL9 T! 2EA4ARER2 ;:! ARE 8N P!22E228!N !4 A C/C 822<E/ <N/ER M.2. %C/C+ R<LE2 )D,-3 ;:8C: 82 /AMA6E/ AN/ /!E2 N!T :A7E CLEAR /ETA8L23 4EAT<RE2 AN/ P:T!6RAP: !R !T:ER;82E /E4ACE/ !R M<T8LATE/ +
No -ref- da#le fee of Rs.)3---$" %Rupees !ne Thousan# onl.+ for Replaceme t of CDC+ to #e paid thro-gh Dema d Draft from a ! atio ali&ed #a , draw i fa1o-r of re%pecti1e 4hippi g Ma%ter+ pa!a#le at M-m#ai56ol,ata5Che ai+ to #e e clo%ed"'$)".rigi al CDC i% to #e e clo%ed alo g with the applicatio for replaceme t of CDC2-

/etails of C/C. C/C No 8ssue# at /ate of issue 8ssue# b.

?. A##ress to sen# Renewal Certifi1ate or C/C b. RE682TE/ P!2T 2

:ouse NoA 2treetA 7illage $ Post !ffi1e $ Tehsil /istri1tA 2tate Phone with 2T/ Co#e

P8N Co#e E"mail

/ECLARAT8!N
8 hereb. #e1lare that all the statements ma#e in this appli1ation are true an# 1omplete to the best of m. 0nowle#ge an# belief an# nothing has been 1on1eale#$#istorte#. *. 8 hereb. submit that 8 am the hol#er of C/C NoE..EEEEEEEE... issue# from the port ofEEEEEE.. .

3 3. 8 am aware that3 if at an. time3 8 am foun# to ha e 1on1eale#$#istorte# an. material information an# the 2hipping Master has reasons to belie e that 8 ha e obtaine# the C/C b. false or erroneous information3 m. C/C will be 1an1elle#$suspen#e# forthwith as per the pro isions 1ontaine# in Rule )- of the Mer1hant 2hipping %Continuous /is1harge Certifi1ate"1um"2eafarers 8#entit. /o1ument+ Rules3 *--)3 as amen#e#.

Pla1e AEEEEEEEE. /ate AEEEEEEEE.

2ignature of the Appli1antAEEEEEEEEE. Name of the Appli1antAEEEEEEEEEEEEE

2PEC8MEN 286NAT<RE2 !4 T:E APPL8CANT % !nl. in 1ase of /upli1ate $ Repla1ment of C/C + '4ig at-re% are to #e co fi ed to each of the #o*e%) / $ (