FORM- 019/SMAA

GOVERNMENT OF SAMOA
Samoa Maritime Authority & Administration
MINISTRY OF WORKS, TRANSPORT & INFRASTRUCTURE, APIA, SAMOA
Technical Office: ASCENT NAVALS, 61/2-3, Sailourd Road, Paknam, Samutprakan, Thailand
Phone: +66-027017277, E.Mail:manager@ascent-mwti.com, www.ascentregister.com

APPLICATION FOR ISSUE OF CERTIFICATE OF ENDORSMENT (COE)

Application: All Officers working onboard Commonwealth of Samoa. Flag Ship

Name of the Vessel:
(A) Details of Officers – See explanatory Notes for help on form filling.
S. No. Name as on COC Nationality Date of Birth (ddmmyy)

(B) COC details of Officers – as numbered above

S. No. COC/Certificate of Proficiency No. COC Grade/capacity COC Issuing COC Date
Authority Issue Date (ddmmyy) Expiry Date (ddmmyy)

Declaration by Applicant
I declare that the particulars contained in this application are correct. I also declare that the Master,
Chief Engineer Officer Or Second Engineer Officers (Management level) have an appropriate knowledge
of Commonwealth of Samoa legislation relevant to the functions they are permitted to perform.
Billing Name/Address:

Courier Address (If Different from others)

Name (In block letter) Sign & Stamp

Owner Agent Person
Applying

Date: Telephone No. Email Address:

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COE/10/16/Rev: 00
 FORM- 019/SMAA

GOVERNMENT OF SAMOA
Samoa Maritime Authority & Administration
MINISTRY OF WORKS, TRANSPORT & INFRASTRUCTURE, APIA, SAMOA
Technical Office: ASCENT NAVALS, 61/2-3, Sailourd Road, Paknam, Samutprakan, Thailand
Phone: +66-027017277, E.Mail:manager@ascent-mwti.com, www.ascentregister.com

EXPLANATORY NOTES – Application Form for CWS COE

This form allows the application forms up to 8 crew endorsement (can be any type ie. COE/GOC/SSO/DCE/ROC etc.)
If any person applying for more than one type of crew endorsement (eg. Master may apply for COE and GOC ) then please fill
up his name twice in section (A)with the corresponding COC details in section (B).
If more than 8 Crew Endorsements are applied then please go for this form.

(A) Details of Officers – See explanatory Notes for help on form filling.
S. No. Name as on COC Nationality Date of Birth (dd mm yyyy)
1
2
3

(B) COC details of Officers – as numbered above

S. No. COC/Certificate of Proficiency No. COC Grade/capacity COC Issuing COC Date
Authority Issue Date (dd/mm/yyyy) Expiry Date (dd/mm/yyyy)
1
2
3

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COE/10/16/Rev: 00