(Company name)

Annex F

IMO CREW LIST

(IMO FAL Form 5)

Page Number

Arrival Departure
1.1 Name of ship 1.2 IMO number

1.3 Call sign 1.4 Voyage number

2. Port of arrival/departure 3. Date of arrival/departure

4. Flag state of ship 5. Last port of call

6 No. 7. Family name, given names 8. Rank or rating 9. Nationality 10. Date and 11. Nature and
place of birth number of identity
document

12. Date and signature by master, authorized agent or officer

Annex E

Republic of the Philippines

Office of the President

COMMISIION ON HIGHER EDUCATION

Department of Transportation and Communications

MARITIME INDUSTRY AUTHORITY

CERTIFICATE OF SEA SERVICE

 Sir / Madam:

This is to certify that _____________________ holder of SIRB

No.____________ has been employed by this company with the following sea going service/s:

Period Covered Total Sea

Route Gross
Name of Vessel Type (Foreign / Tonnage
KW
Registry From To Position
service
Power Y/M/D Y/M/D / Rank
Domestic) (GT) Y-M-D

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

Issued this day of at .

COMPANY SEAL
President / Duly Authorized Person
Signature above Printed Name

SUBSCRIBED AND SWORN to before me this day of , 20 ,

Doc No. :
Page No. :
Book No. :
Series of : Notary Public

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

Annex D
Republic of the Philippines
Office of the President
COMMISSION ON HIGHER EDUCATION

Department of Transportation and Communications

MARITIME INDUSTRY AUTHORITY
CERTIFICATE OF SEA SERVICE
This certifies that _______________________________________________ had actually served under
our Supervision onboard ______________________________, _______________________________
(Name of Vessel) (Type of Vessel)
of _______________________ with Registry No. , ____________, ___________________________
vessel
(Vessel Nationality) (Near Coastal/Sea-going)
of _________ Kilo watt and _________ Gross Tonnage for a period of __________________________
(No. of Years)(Months)(Days)
from __________________ to __________________ as ______________________
(Date Embarkation) (Date of Discharge) (Position Held)

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

Issued this _____ day of _____________________ at _________________________.

SEAL OF VESSEL
________________________________
Master-Signature above Printed Name

Nationality : __________________________
Kind of License : __________________________
Registration No. : __________________________
Date of Registration : __________________________
Expiry Date : __________________________

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