FORM: MQAF 16.

42

APPLICATION FOR SEA TIME CALCULATION

A - PERSONAL DETAILS: Applicants must complete this section

Name
Date of Birth
Place of Birth
Nationality
Gender
Martial Status
Applicant Personal Contact Details Phone: Email:
Applicant Resident/Private Postal
Address

B – EMPLOYMENT DETAILS: All applicants must complete this section

Employer (name)
Employer Crewing Officer (name)
Employer Contact Details (phone)
Employer Contact Details (email)
Postal Address

C – PURPOSE OF APPLICATION: Applicants to select or choose either 1, 2, or 3 as the purpose of the application. Place a TICK in the next column to select.

No LIST OF PURPOSE OF APPLICATION Place a Tick

1 NMSA Written & Orals Examination ☐

2 Eligibility Letter for COURSE STUDY at an Maritime Training Institute ☐

D – SUPPORTING DOCUMENTATION: These NMSA Requirements must be attached with the application.

NMSA REQUIREMENTS Expiry Date In place or Pending (Remarks

1. Sea Service Records

2. Certificate of Competency (Copy)
 3. SOLAS Safety Training Copies
4. Security Training Certs
5. Medical Fitness Certificate
6. GMDSS/Radio License (Deck Officers only)
7. Payment of FEES Remittance or Receipt attached
8. Statutory Declaration Statement

E – METHOD OF APPLICATION LODGEMENT: Applicant must indicate method of lodgement by placing a tick on below methods.
✘ Email Post Application submitted in person

Do you require your certificate to be returned to you by courier?

✘ No

Yes

If Yes - A courier fee of K100 is charged and added to the normal NMSA certificate processing fees.

Date Application Lodged:

…………………………………….
Click or tap to enter a date.

Name of Sender:……………………….

F – DECLARATION
To the best of my knowledge, the information given by
me in this application is true and correct in every detail………………………………………………… ……. /……. /20…...
Signature of Application

NOTE: Submitting this form DOES NOT automatically entitle the applicant to receive the certificate applied for nor is it acceptance of sea service. The final decision with regard to
the issue of a certificate is made by the Manager, Qualifications & Crewing Dept.

Date Application Received:

………………………………
Click or tap to enter a date.

Receiving Officer:…………………