VESSEL

FLAG

DATE
LOCATION

SEAFARER’S NAME
SEAFARER’S RANK

NOTICE OF PENALTY

An investigation was conducted on:

DATE TIME

to determine whether or not you are guilty of the following offense/s:

OFFENSE/S (as provided in Section 33 of the PENALTY
POEA Standard Employment Contract)

You have been ordered to explain your acts, and while the same is duly noted, it has been
deemed unsatisfactory.

In light of the foregoing, you are hereby found guilty of the above-stated offense/s charged.
The proper penalty as provided is hereby imposed, without prejudice to any other charges or
claims which may be brought against you as a consequence of your acts.

MASTER SEAFARER

_______________________________ _______________________________
Signature over printed name Signature over printed name