form ol/si3 APPURATION FOR REPUBLIC OF VANUATU SEAFARER DOCUMENTS PORT VILA, VANUATU This Document must be led hr combletey and ley inorder to have documents laud I_Reason for Application | ClEAR | PRINT Co SEAFARERS ID BOOK —_[[] LICENSE/ENDORSEMENT (Check both boxes if applying for both documents) Check one: [] ORIGINAL [] RENEWAL [] REPLACEMENT W requesting a duplicate for a lost or stolen License/D Book afach a signed statement explaining how, winen and where your eredentals were lost or stolen and your efforts to recover them, VESSEL NAME. OFFICIAL NUMBER (VesseL Nawe aio Orrcat WoMBERIE WOT REGUREDFOR AW APPUCATION SUBMITTED BY AM NOAOUA. BERFERERNOTYETWORENG OWA VAMUATU FLAGGED ‘vesset) DESIGNATE ALL LICENSES OR ENDORSEMENTS BEING APPLIED FOR BELOW: Master Chief Officer |] Navigating Officer of the Watch | [REO (Electronics) Chief Engineer | CT 2nd Enginear | LT Engineering Officer of the Watch TC] GOC ‘Abie Seaman Oasis TI Ordinary Seaman ROC Motorman 1 Tifeboatman | T] RTO (telephony) /RMO TT Other MODU Documents ‘IM 11 Barge Supervisor (7 Ballast Control Operator |] Maintenance Supervisor Il. Personal Information ast Family Name (Surname) Widate Name ] Date of Bit (ODMMIYY) First/ Given Name | Place of Birth (ity & Country) Citizenship Height Weight | Hair Color Eye Color | CY) Wale [Female Ft_/ Ccm | (bb / Ong! Distinguishing Marks (Scars, Tattoos, Birthmarks, ete, Permanent Address Please staple, glue two pictures ee or if filing by email attach a Maling|Addrees for Seaman's Documents picture in "jpeg" format. The size of should be about 15kb. Person to Notify in Case of an Relationship to You ‘Address & Telephone Number of Person =) Fon OL/S8 2016)Il. Description of Highest Grade License/Endorsements LICENSE? ae ENDORSEMENT LICENSE NUMBER Expiranion Dare | IssuiN CounTRY Date GRADE Vanuatu Nation Gmpss COMPLETE FOLLOWING INFORMATION AS PER YOUR NATIONAL CERTIFICATE ‘Capacity FUNCTIONS Lever LIMITATIONS “ATTACH COPIES OF OTHER LICENSES OR ENDORSEMENTS ‘“* M= Management / 0 = Operational / S = Support ‘+ Have you ever been denied mariner documents by any other fiag? ClYes [No + Have you ever had any license issued to you revoked or suspended? ClYes [No + Have you ever been convicted of a crime? OYves [)No (If YES to any of the above, attach a full explanation of the circumstances and outcome to this application) IV. SEA SERVICE Notes: 1. List all vessels you have served on in the past 5 years. 2. Proof of sea service must be from seaman’s book or certificates of service. Copies are accepted. 3. if additional sp: jeeded, attach additional pages. Power Vessel an. | cya Flag [Glonane Lome | us Laver Tovevs DPnz B.C. Saadine Zanzibar Form OL/S9 (2018)GENERAL INFORMATION AND INSTRUCTIONS **** MISSING DOCUMENTATION WILL RESULT IN PROCESSING DELAYS AND / OR REJECTION OF THE APPLICATION. **** Please read the following instructions carefully and enter all required information. This application may be completed electronically; printed for signatures; and mailed to the Republic of Vanuatu along with all supporting documentation required. APPLICATIONS ‘= Application for Renewal of Seafarer Documents - OU/SI 3 '* Medical Form - MEDIC PHOTOGRAPHS - Photos must be in color and portray a good likeness of applicant for satisfactory identification: ‘= TWO (2) passpor size (2"x 2”) photos + Facial front view of applicant '» Taken no more than 1 year from the time application is submitted + Applicant's name is to be printed on the reverse side of the photograph IME ‘* Avalid seaman’s document from the maritime nation in which the original Vanuatu Endorsement was issued. PROOF OF SEA SERVICE (See PartV of aplication) PROOF OF NATIONAL LICENSE/ENDORSEMENT - A certified copy of applicant's national license and STCW endorsement, if MISCELLANEOUS - In the event approval of this application is not granted, a processing fee will be charged to the applicant, and ‘documents will be disposed of by Vanuatu. RENEWAL APPLICATIONS - In addition to the above requirements, a copy of the previouely issued Vanuatu ID book or officer license/endorsement must be included. FEE SCHEDULE - Payment must be made by check, money order, or wire transfer drawn on a US Bank and payable in US dollars to Vanuatu Maritime Services Limited. ‘Seaman ID Book... — Master / Chief Engineer License / Endorsement / OIM / Ballast Control Operator. Chief Officer / 2ND Engineer / Maintenance or Barge Supervisor All Other Officer Licenses / Endorsements including GOC / RTO / REO / RMO / ROC API AND DOCUMENT: D ONE OF THE FOLL E: Vanuatu Maritime Services Limited 39 Broadway, Suite 2020 New York, NY10006 licensing@vanuatuships.com VANUATU MARITIME SERVICES LIMITED, IKESHITA Building 3F, 5-1-2, Naka-Kasai Edogawa-Ku Tokyo 134-0083 Japan vanuatuships@fronts.jp SEA ROAD SHIPPING & AGENCY CO., LTD. Room 504, Youngdong Bidg. #1212-4, Choryang 1-Dong. Dong-Ku Busan Korea searoad@srssms.com KLAS SHIPPING CONSULTANCY & SURVEY LTD. Tunel Yolu Cad.Yali Yolu sok. Ismail Ergin Is Merkezi No:54 B Blok Kat 3 Daire 6 Ustbostanci Istanbul Turkey klas@klassurvey.com 1/83 2016)V. Declaration of Applicant 1 hereby declare that: ‘Applicant Name 1 Alliniormation and supporting documents | have provided wih this aplication ar re, othe bos of my knowede. 2. have ead and understood Vanuatu Mrtime Buetin 108, “Legislation and Responibitis’ and '3._ wil abide by the Varuatu Mariime Act and Regulation, the various conventions and mandatory codes addressed inthe Act and Reguations, and {he reguiations prescnbed by all appcable intemational conventions and codes. | understand that any information or attached document(s) found to be fraudulent in this application will nullity the application and any ‘documents lssved thereof. | furthor understand, should the documents and Information provided herewith be found fraudulent 1 will be ‘Prohibited from future employment on Vanuatu fag vessels, and my name willbe reported to other flag administrations. ‘An Orginal Signature ofthe Applicant le required. However, an Elecivonie ‘Signature with the Company's stamp & Signature of an Authorized Placement Oficial together wil sufice in cases where the Applicant is plying fora renewal and is serving on board the vessel atthe time of submitting the application. ‘Signature of the Applicant Original or Electronic ‘Signature of Placement Oficial VI. Radio Operator Declaration 4 hereby declare that: ‘Applicant Name In connection with my service onboard vessels registered unde the laws and regulations ofthe Republic of Vanuatu, | agree t: 1 Maintain secrcy in ratio comespondence: 2, Refrain rom unauthorized interception of radio communication nt intended for pubic genera se 3. _Reftain rom dsciosing the existence of any radio communication not intended for pubic gonera use; and 4. Conform tothe reguiations annexed othe Intemational Tetocommunications Union Convention in fore, and al laws and regulation ofthe Republic ‘of Vanuatu applicable to the operation of ship radio stations, ‘An Original Signature af the Applicant le required. However, an Electronic ‘Signature with te Company's stamp & Signatur ofan Authorized Placement Official together wil suffice in casos where the Applicant renewal and is serving on board the vessel atthe time of. application. ‘Signature of the Applicant Original or Electronic Fom 0/83 2016)