NOT FOR SALE

JOHN B. LACSON FOUNDATION MARITIME UNIVERSITY - (MOLO), INC.

(formerly Iloilo Maritime Academy)
M. H. del Pilar Street, Molo, Iloilo City, 5000 Philippines
Fax / Tel. Nos. (63) (33) 3365449
E-mail: admin.molo@jblfmu.edu.ph
www.jblfmu.edu.ph

CERTIFICATE OF SEA SERVICE

(All statement herein are subject to verification)

TO THE BOARD OF MARINE ENGINEER OFFICERS:

THIS CERTIFIES that ________________________________________________ had actually served under our

supervision on board _______________________, ______________________, ____________________________

(Name of Vessel) (Type of Vessel) (State the Nationality of Vessel)

with Registry No.: _________a _______________________vessel of ____________KW and __________gross tonnage

(Near Coastal/ Seagoing)

for a period of _______________________________________from ____________________ to _________________

(No. of Years) (Months) (Days) (Date of Embarkation) (Date of Discharge)

as_______________________.
(Position Held)

This certifies further that the above-stated data are all true and that any false statement/s made
therein shall be a ground for criminal prosecution.

Issued this _______________________ day of _________________________ at__________________________.

SEAL OF VESSEL
SEAL OF COMPANY

____________________________________
Master-Signature above Printed Name

____________________________________________ Nationality : ________________________

Name and Signature of Port Captain/ Personnel Mgr. Kind of License : ________________________
Registration No. :_________________________
________ ________________________________ Date of Registration : ________________________
Name of Local Shipowner of Manning Agent Expiry Date : ________________________

Address: _______________________________ ______________________________________________

____________________________ Chief Engineer Signature Above Printed Name
Telephone Nos. ______________________
Nationality : ________________________
Kind of License : ________________________
Registration No. :________________________
Date of Registration : ________________________
Expiry Date : ________________________

SUBSCRIBED AND SWORN TO before me this _____ day of __________________, 20_______

at ___________________________.

Doc. No. :__________

Page No. :__________
Book No. :__________ _________________________
Series of : __________ NOTARY PUBLIC

Note: This form is good only for use (1) vessel. This form can be reproduced. Any erasure/obliteration be a
ground or denial.