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The Commonwealth of Dominica Office of the Maritime Administrator

CDMP-5000-E Marine Personnel Application Package

for Endorsement of Foreign Officers

CDMP-5000-E Rev01

THE COMMONWEALTH OF DOMINICA Office of the Maritime Administrator

APPLICATION FOR ENDORSEMENT OF FOREIGN OFFICERS PERSONNEL

MAKE SURE ALL BOXES ARE COMPLETED. TYPE OR PRINT CLEARLY. PART I. PERSONAL DESCRIPTION AND INFORMATION: 1. Last Name (Family Name) First Name (Given Name) Middle Initial 2. Date of Birth

day month year

3. Place of Birth (City and Country)

4. Permanent address (street, city and country) Telephone: Email:

5. Address to which certificate is to be mailed. Telephone: Email:

6. Name and relationship of person to be notified in emergency. Telephone: Email:

7. Citizenship

7a. Passport Number

8. Height 9. Weight

10. Color of Hair

11. Color of eyes 12. Distinguishing Marks 13. Sex � Male � Female

14. I am currently serving onboard vessel: ___________________________________ 15. Date of Application: ___________________ PART II. APPLICATION TYPE - Fill out box A or B below. All applicants are required to hold a valid Identification & Discharge Book along with their Endorsement Certificate A. OFFICER ENDORSEMENT- I HOLD A FOREIGN OFFICER CERTIFICATE/LICENSE AND AM APPLYING FOR:

Certificate of Endorsement AND Seafarer’s Identification & Discharge Book

B. RENEWAL/UPGRADE: I HAVE RENEWED OR UPGRADED MY FOREIGN CERTIFICATE OR ENDORSEMENT AND AM APPLYING FOR A RENEWAL OR UPGRADE OF MY DOMINICA ISSUED ENDORSEMENT AND/OR ID BOOK

Renewal or Upgrade of Certificate of Endorsement and /or Seafarer’s Identification & Discharge Book

PART III. CURRENT LICENSE OR ENDORSEMENT INFORMATION: Complete items 16 – 19 below and select STCW grade below with any limitations or special qualifications noted that are required. 16. Certificate #: ______________________________________ 17. Country of Issue:______________________________ 18. Issue Date: _____________________________ 19. Expiry Date:_____________________________

Deck Officers Engineering Officers Grade < 500 GT 500<>3000 > 3000 GT Grade < 750kW 750 <> 3000 kW > 3000 kW Master II/3 II/2 II/2 Ch. Engineer III/3 III/2 III/2 Chief Mate II/3 II/2 II/2 2nd Engineer III/3 III/3 III/2 OICNW N/A N/A II/1 OICEW N/A III/1 III/1 Electro-Technical Officer III/6 Note Limitations here:

Near Coastal Not for Service on Tankers Steam Motor Other _____________________________________ Special Qualification/Training

V/1 – Tanker Personnel □Oil □ LNG □ LPG □ Chemical

V/2 – Personnel Passenger Vessels

VI/6 – Security Awareness Training or Security Training

IV/2 – GMDSS/ROC

CDMP-5000-E Rev01

Applicant Name:

Date of Birth:

PART IV. SEA SERVICE List and submit proof of at least the minimum service required during the last five years or more to establish eligibility for the Certificate of Competence requested. Copies of discharge book pages may be submitted in lieu of this table.

Propulsion (Steam or Motor)

Name of Vessel Deck Officers list Gross Tons/ Engineers list kW Propulsion Power

Flag Name of Managing Operator

Capacity in which served Period of Service Total Service From To

years months

days month day year month day year

PART V. APPLICANTS FOR RADIO OPERATORS CERTIFICATE MUST READ AND SIGN THIS OBLIGATION: By affirming my signature below, I acknowledge that I am obliged to ensure and maintain the secrecy of all telecommunications of which I may gain knowledge in the course of my services, and that I am likewise obliged not to reveal the existence or contents of any correspondence to anyone other than the addressee. My signature further acknowledges that, if I should breach these obligations, my Certificate of Competence issued pursuant to this application may be suspended and/or revoked. Signature

PART VI. APPLICANTS FOR STCW’95 CERTIFICATE OF COMPETENCE AT THE MANAGEMENT LEVEL MUST SIGN THIS AFFIDAVIT/ACKNOWLEDGMENT. These applicants include Master and Chief Mate applicants for the service on board ships of 500 gross tonnage or more, as well as Chief Engineer and Second Engineer applicants for service on board ships powered by main propulsion machinery of 750 kW propulsion power or more. I hereby understand that I will receive from the Administration a copy of the publication CDP-301, (“Familiarization with National Maritime Legislation”), which I will acknowledge and affirm I will review to ensure that I become familiar with the national maritime legislation of the Commonwealth of Dominica relevant to the functions to be performed by me for which I have applied to be certificated. Signature

Copies of the following identity documents (with name and numbers visible) indicated below are being submitted with this application. Originals are required at time of testing: Seafarer’s Book or Card Passport Commonwealth of Dominica or Foreign Certificate ( if applicable)

PART VII. AFFIDAVIT OF APPLICANT APPLICATION CANNOT BE ISSUED UNLESS APPLICANT SIGNS BELOW I hereby affirm that all information provided by me in this application and its supporting documents and proofs are true and correct to the best of my knowledge and belief; further, that no certificate issued to me heretofore by any Government has ever been revoked or suspended; or, if revoked or suspended, a full explanation of the circumstances is attached hereto and made part of this application. Date of Application Signature of Applicant

CDMP-5000-E Rev01

PART VII. IDENTIFICATION INFORMATION MARINER APPLICANT FULL NAME : DATE OF BIRTH: PASSPORT# Signature: Please use the space below to sign your name clearly, without touching any of the box lines. This signature will be transferred to your Seafarer’s ID book.

Thumbprint: Please use the spaces below for 2 copies each of your left and right thumbprint. Using a traditional blue or black inkpad, roll your thumb from the outer edge over to the right edge in the inkpad and then in the space below, roll from left to right onto the paper to create a clear imprint (repeat the process of inking and transferring for each imprint). We are asking for multiple imprints, so we may select the clearest one for imprinting on your Seafarer’s ID book.

LEFT THUMB RIGHT THUMB Thumbprint 1

Thumbprint 2

Thumbprint 1

Thumbprint 2

EXAMPLES

Please note that applications that are submitted with unacceptable photo, thumbprint or signature shall be returned to the applicant for resubmission.

Bad

Good

PLEASE STAY WITHIN THE LINES

PHOTO - ORIGINAL COLOR PHOTO - CLEAR RESOLUTION

CDMP-5000-E Rev01

PART IX GENERAL INFORMATION AND INSTRUCTIONS FOR APPLICATION FOR ENDORSEMENT OF FOREIGN OFFICER READ INSTRUCTIONS CAREFULLY. Enter all required information. Please use computer, typewriter or print legibly. Failure to properly complete this application or to submit required supporting proofs, etc. will result in rejection of the application or delay its approval. All documents not presented in the English Language must have certified English translations attached and enclosed with the application. PLEASE DO NOT STAPLE THE APPLICATION OR ITS ATTACHMENTS. GENERAL INFORMATION

1. National certificates from the countries on the IMO White List (http://www.imo.org/includes/blastDataOnly.asp/data_id%3D26383/1163-Rev-4.pdf) are recognized for the issuance of equivalent Dominica Endorsements under the provisions of STCW95.Please note that Dominica may experience delays in acquiring verification from some Flag Administrations, which may delay the issuance of Permanent COCs and Endorsements. Temporary Certificates of Receipt of Application can be issued by Dominica for periods of 90 days for a fee and may be renewed at cost for up to a full period of “1” year.

2. This application is subject to the approval of the Maritime Administrator, Commonwealth of Dominica. In the event approval is not granted, all application documents together with the issuance fee shall be returned to the applicant at the mailing address indicated. If the application is approved, the issued certificate/identification book will be sent to the mailing address indicated. The ‘certified copy’ of Form CDMP-5000B is to be retained by the seafarer as evidence that the application is being processed.

3. Seafarer’s ID and Discharge Book: This identification document conforms to the requirements of the International Labor Organization (ILO) Convention No. 108 (Seafarer's Identity Documents Convention, 1958). It is issued to seafarers of Commonwealth of Dominica flag vessels for use when traveling to or from an assigned vessel or pursuant to instructions from the master of such a vessel. Other uses of the book must be in conformity with Commonwealth of Dominica regulations. ILO 108 does not in any way restrict the right of a member nation from preventing any particular individual from entering or remaining in its territory.

4. Seafarer's Identification Document & Discharge Book and Training Record Books are issued under the authority of Chapter 8 of International Maritime Act 2000, as amended. The SID and TRB remains the property of the Maritime Administrator and may be withdrawn at any time. It may not be altered in any way nor be allowed to pass into the possession of an unauthorized person. If the TRB becomes filled with entries, requires alteration, becomes damaged, application for a replacement TRB should be made immediately. If the SID/TRB is stolen, lost, or accidentally destroyed, notification should be given immediately to any office of the Maritime Administrator, and an application for a replacement SID/TRB may be made.

5. AGE AND CITIZENSHIP REQUIREMENTS. Applicants for Certificate of Competences as OICNW, OICEW, Radiotelegraph Operator, Radio Telephone Operator and GMDSS Operator must be at least 18 years of age; applicants for all other grades of certificates must be at least 21 years of age. Applicants may be of any nationality and need not be citizens or residents of the Commonwealth of Dominica.

6. TRAINING AND SEA SERVICE REQUIREMENTS. Applicants for Dominica certificate or endorsement must meet the applicable training and sea-time requirements. Appendix A lists these requirements by STCW regulation number, including training required for personnel on certain types of ships.

7. This application is subject to the approval of the Maritime Administrator, Commonwealth of Dominica. In the event approval is not granted, the documents listed in paragraph 3 above together with the fee shall be returned to the applicant at the mailing address indicated. If the application is approved, the SID/TRB will be sent to the mailing address indicated. The ‘certified copy’ of Form CDMP-5000B is to be retained by the seafarer as evidence that the application is being processed.

DOCUMENTS TO BE FILED WITH APPLICATION. The following documents, letter and proofs must be submitted together with this application (See Appendix A for requirements by STCW Regulation)

� Three (3) photographs - facial front view of applicant, passport size, taken within one (1) year preceding application with applicant's signature and name printed on reverse side. Photos may be black and white or color and be 2.0" x 2.0" (50 mm. x 50 mm.) in size. Please do not staple.

� Physical Examination Report (From CDMP-5000B in this package). - The physical examination must be carried out not more than 12 months prior to date of making application.

� Identity Document - A copy of a valid passport along with a valid seaman's document from another maritime nation. A copy of these documents must be submitted with the application. Applications for renewal must include a copy of the previously issued documents as proof of identity. If the documents presented are not in the English language, a certified translation of the documents into English must also be enclosed with the application. These certified translations must identify the translator for verification purposes.

� Proof of foreign Certificate of Competence - Any foreign Certificate of Competence must have a valid “STCW Convention Endorsement” and be issued by a country recognized by the Commonwealth of Dominica. Submit original foreign certificate (which will be promptly returned to the applicant) or a duplicate original of the foreign certificate which is relied upon; or a clear photocopy of the original authenticated by the issuing authority or by a consular officer of the issuing state; or a clear photocopy of the original plus a current certificate of the issuing authority describing the certificate and the holder so as to identify both; or a clear photocopy made by a notary public, commissioner for oaths or other officer authorized by law to administer oaths, verifying that such officer made the photocopy from the original presented to him, and attaching the customary certificate of a public official authenticating the signature of such notary, commissioner or officer.

� Proof of completion of nautical, marine engineering or radio school training - submit one (1) copy of course completion certificate, if applicable. � Proof of foreign training certificate - radar simulator training, advanced firefighting training, GMDSS certification, first aid training, advanced medical training, survival craft/rescue boat

training, and automatic radar plotting aids (ARPA) training - submit one (1) copy of foreign certificate if national Certificate of Competence does not require this training. SCHEDULE OF FEES.

Certification Requirement Fee Renewal/Re-Test

Issuance of Endorsement by Recognition of COC $ 175.00 $ 175.00

GMDSS Only $ 150.00 $ 150.00

Special Qualification Certificate (BST, etc.) $ 150.00 $ 150.00

Special Qualifications added to Certificate or Endorsement $ 50.00 $ 50.00

Seafarer Identification and Discharge Book $ 75.00 $ 75.00

Replacement of lost Identification Card or Book $ 50.00 n/a

Replacement of Lost Certificate or Endorsement $ 100.00 n/a

Replacement of Lost Special Qualification $ 50.00 n/a

Issuance of Certificate of Receipt of Application $ 50.00 $ 50.00

Letter of Receipt (confirmation of applications received for crew on a vessel; Maximum 6 mariners per letter) – issued immediately

$ 150.00 $ 150.00

Courier Fees - International - Caribbean - Domestic

$ 90.00 $ 60.00 $ 50.00

n/a

Payment must be made by check, credit card, wire or money order drawn on a U.S. Bank and payable in U.S. dollars to "Dominica Maritime Registry, Inc.

http://www.imo.org/includes/blastDataOnly.asp/data_id%3D26383/1163-Rev-4.pdf

CDMP-5000-E Rev01

Appendix A

Deck Licenses

REG: II/1

Officer in charge of a navigational watch, on ships of 500 gross tonnage or more LEVEL: OPERATIONAL

General Requirements Training Requirements (Submit copies of training certificates) □ Age – 18 years

o Submit copy of Passport □ Sea service - 3 years sea-service or 1 year

sea service as part of approved training program o Submit Sea Service Letters or copies of

discharge papers o 1/3 of Sea time must be completed on

ships of respective tonnage/propulsion power according to application

□ Min. 6 months supervised bridge watch duties during sea time

o Submit letter from Company/Vessel □ Dominica Application and Medical Report

o Ensure application is complete o Include copy(s) of any previously or

currently held licenses or Certificates of Competency

□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Celestial Navigation □ Advanced Firefighting □ ECDIS* □ Radar □ OICNW > 500 GT Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties □ Ship Security Officer Training**

* ARPA, ECDIS and GMDSS training is required only for personnel serving on ships with the respective equipment installed. + Medical First Aid Proficiency course required for those designated to provide medical care on board ship. Proficiency for Persons in Charge of Medical Care required for those designated to take charge of medical care on board ship. ΦΦProficiency in Fast Rescue Boats training is required only for personnel serving on ships with Fast Rescue Boats ** Ship Security Officer training required only if serving in that capacity

REG: II/2.3

Master on ships of between 500 & 3000 gross tonnage, NEAR COASTAL LEVEL: MANAGEMENT

General Requirements Training Requirements □ Age – 20 years

o Submit copy of passport □ Sea service - 36 months as OICNW or 24

months as OICNW with 12 months service as Chief Mate o Submit Sea Service Letters or copies of



□ Dominica Application and Medical Report o Ensure application is complete o Include copy(s) of any previously or


□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Advanced Firefighting □ ECDIS* □ Radar □ Master/Mate greater than 500 GT □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties □ Ship Security Officer Training**


CDMP-5000-E Rev01

REG: II/2.3

Chief mate on ships of between 500 & 3000 gross tonnage, NEAR COASTAL LEVEL: MANAGEMENT


o Submit copy of passport

□ Sea service – 12 months as OICNW o Submit Sea Service Letters or copies of

discharge papers o 1/3 of Sea time must be completed on ships of

respective tonnage/propulsion power according to application

□ Dominica Application and Medical Report o Ensure application is complete o Include copy(s) of any previously or currently

held licenses or Certificates of Competency



REG: II/2.1

Master on ships of 3000 gross tonnage or more, NEAR COASTAL LEVEL: MANAGEMENT



□ Sea service - 36 months as OICNW or 24 months as OICNW with 12 months service as Chief Mate o Submit Sea Service Letters or copies of







CDMP-5000-E Rev01

REG: II/2.1

Chief mate on ships of 3000 gross tonnage or more, NEAR COASTAL LEVEL: MANAGEMENT



□ Sea service - 12 months as OICNW o Submit Sea Service Letters or copies of







REG: II/2.1

Master on ships of 3000 gross tonnage or more, OCEANS LEVEL: MANAGEMENT




discharge papers o 1/3 of Sea time must be completed on ships

of respective tonnage/propulsion power according to application



□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Celestial Navigation □ Advanced Firefighting □ ECDIS* □ Radar □ Master/Mate greater than 500 GT □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties □ Ship Security Officer Training**


CDMP-5000-E Rev01

REG: II/2.1

Chief mate on ships of 3000 gross tonnage or more, OCEANS LEVEL: MANAGEMENT










REG: II/2.3

Master on ships of between 500 & 3000 gross tonnage, OCEANS LEVEL: MANAGEMENT










CDMP-5000-E Rev01

REG: II/2.3

Chief mate on ships of between 500 & 3000 gross tonnage, OCEANS LEVEL: MANAGEMENT










REG: II/3

Officer in charge of a navigational watch on ships of less than 500 gross tonnage, Oceans LEVEL: OPERATIONAL



□ Sea service - Must hold certificate for OICNW > 500 gt: o 3 years sea-service or 1 year sea service as

part of approved training program o Submit Sea Service Letters or copies of




o Submit letter from Company/Vessel



□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Celestial Navigation □ Advanced Firefighting □ ECDIS* □ Radar □ OICNW > 500 GT Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ

* ARPA, ECDIS and GMDSS training is required only for personnel serving on ships with the respective equipment installed. + Medical First Aid Proficiency course required for those designated to provide medical care on board ship. Proficiency for Persons in Charge of Medical Care required for those designated to take charge of medical care on board ship. ΦΦProficiency in Fast Rescue Boats training is required only for personnel serving on ships with Fast Rescue Boats

CDMP-5000-E Rev01

REG: II/2.3

Masters on ships of less than 500 gross tonnage, Oceans LEVEL: MANAGEMENT



□ Sea service - Must hold certificate for Master 500 – 3,000 gt (see II/2)

o 36 months as OICNW or 24 months as OICNW with 12 months service as Chief Mate

o Submit Sea Service Letters or copies of discharge papers

o 1/3 of Sea time must be completed on ships of respective tonnage/propulsion power according to application



□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Celestial Navigation □ Advanced Firefighting □ ECDIS* □ Radar □ Master/Mate greater than 500 GT □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ

* ARPA, ECDIS and GMDSS training is required only for personnel serving on ships with the respective equipment installed. + Medical First Aid Proficiency course required for those designated to provide medical care on board ship. Proficiency for Persons in Charge of Medical Care required for those designated to take charge of medical care on board ship. ΦΦProficiency in Fast Rescue Boats training is required only for personnel serving on ships with Fast Rescue Boats

REG: II/3

Officer in charge of a navigational watch on ships of less than 500 gross tonnage, Near Coastal

LEVEL: OPERATIONAL


o Submit copy of Passport □ Sea Service - 3 years sea-service or 1 year sea

service as part of approved training program o Submit Sea Service Letters or copies of




o Submit letter from Company/Vessel □ Dominica Application and Medical Report

o Ensure application is complete o Include copy(s) of any previously or currently


□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Advanced Firefighting □ ECDIS* □ Radar □ Master/Mate less than 500 GT □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ

* ARPA, ECDIS and GMDSS training is required only for personnel serving on ships with the respective equipment installed. + Medical First Aid Proficiency course required for those designated to provide medical care on board ship. ΦΦProficiency in Fast Rescue Boats training is required only for personnel serving on ships with Fast Rescue Boats

CDMP-5000-E Rev01

REG: II/3

Masters on ships of less than 500 gross tonnage, Near Coastal LEVEL: OPERATIONAL


o Submit copy of Passport □ Sea Service – 12 months as OICNW

o Submit Sea Service Letters or copies of discharge papers

o 1/3 of Sea time must be completed on ships of respective tonnage/propulsion power according to application



□ ARPA* □ GMDSS* □ Basic Safety Training □ Bridge Resource Management □ Advanced Firefighting □ ECDIS* □ Radar □ Master/Mate less than 500 GT OR OICNW > 500 GT Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Proficiency in fast rescue boatsΦΦ

* ARPA, ECDIS and GMDSS training is required only for personnel serving on ships with the respective equipment installed. + Medical First Aid Proficiency course required for those designated to provide medical care on board ship. ΦΦProficiency in Fast Rescue Boats training is required only for personnel serving on ships with Fast Rescue Boats

ENGINE LICENSES REG: III/1

Officer in charge of an engineering watch in a manned engine-room or Designated duty engineer in a periodically unmanned engine-room

LEVEL: OPERATIONAL


o Submit copy of Passport □ Sea Service

o 6 months sea-going plus 30 months training and education with completed TRB for III/1 sea time

o Submit letter from Company/Vessel or copies of pages from discharge book(s)



□ Basic Safety Training □ Advanced Firefighting □ OICEW Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties

+ Medical First Aid Proficiency course required for those designated to provide medical care on board ship. Proficiency for Persons in Charge of Medical Care required for those designated to take charge of medical care on board ship.

CDMP-5000-E Rev01

REG: III/2

Chief engineer officer on ships powered by main propulsion machinery of 3,000 kW propulsion power or more

LEVEL: MANAGEMENT


o Submit copy of passport □ Meet Requirements for OICEW


□ Sea service o 36 months sea service with at least 12

months as a 2nd Engineer on vessel of 3000 kW propulsion power or more



□ Basic Safety Training □ Advanced Firefighting □ Chief Engineer 3000 kW Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties


REG: III/2

Second engineer officer on ships powered by main propulsion machinery of 3,000 kW propulsion power or more

LEVEL: MANAGEMENT


o Submit copy of passport □ Meet Requirements for OICEW


□ Sea service o 12 months sea service as Assistant Engineer or

Engineer Officer on vessel of 3,000 kW propulsion power or more




□ Basic Safety Training □ Advanced Firefighting □ 2nd Engineer 3000 kW Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties


CDMP-5000-E Rev01

REG: III/3

Chief engineer officer on ships powered by main propulsion machinery between 750 & 3000 kW

LEVEL: MANAGEMENT

General Requirements Training Requirements □ Age – 18 years o Submit copy of passport

□ Meet Requirements for OICEW o 6 months sea-going plus 30 months training

and education with completed TRB for III/1 sea time

□ Sea service o 24 months sea service with at least 12

months as a 2nd Engineer on vessel between 750 & 3000 kW propulsion power




□ Basic Safety Training □ Advanced Firefighting □ Chief Engineer between 750&3000 kW Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties


REG: III/3

Second engineer officer on ships powered by main propulsion machinery between 750 & 3000 kW

LEVEL: MANAGEMENT


□ Meet Requirements for OICEW o 6 months sea-going plus 30 months training


□ Sea service o 2nd Engineer Officer: 12 months sea service as

Assistant Engineer or Engineer Officer on vessel between 750 & 3000 kW propulsion power



□ Basic Safety Training □ Advanced Firefighting □ 2nd Engineer between 750&3000 kW Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties

**Note: Qualified 2nd Engineer officers of 3,000 kW or more may serve as chief engineer on vessels less than 3,000 kW, provided that not less than 12 months of sea service was served as an engineer officer in a position of responsibility and certificate is so endorsed + Medical First Aid Proficiency course required for those designated to provide medical care on board ship. Proficiency for Persons in Charge of Medical Care required for those designated to take charge of medical care on board ship.

CDMP-5000-E Rev01

REG: III/1

Officer in charge of an engineering watch in a manned engine-room or Designated duty engineer in a periodically unmanned engine-room on vessels less than 750 kW

LEVEL: Operational


o Submit copy of Passport □ Sea Service: 6 months sea-going plus 30 months

training and education o Submit letter from Company/Vessel or copies

of pages from discharge book(s) □ Dominica Application and Medical Report

o Ensure application is complete o Include copy(s) of any previously or currently


□ Basic Safety Training □ Advanced Firefighting □ OICEW less than 750 kW Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties


REG: III/3

Chief engineer officer on ships powered by main propulsion machinery of less than 750 kW propulsion power

LEVEL: MANAGEMENT


□ Meet Requirements for OICEW <750 kW o 6 months sea-going plus 30 months training


□ Sea service o Chief Engineer officer: 36 months sea service

with at least 12 months as a 2nd Engineer o Submit letter from Company/Vessel or copies

of pages from discharge book(s) □ Dominica Application and Medical Report o Ensure application is complete o Include copy(s) of any previously or currently


□ Basic Safety Training □ Advanced Firefighting □ Chief Engineer less than 750 kW course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties


CDMP-5000-E Rev01

REG: III/6

Electro-technical officer LEVEL: SUPPORT


o Submit copy of Passport □ Sea Service:

o 12 months combined workshop and skills training and approved sea service with completion of the Training Record Book OR

o 36 months of combined workshop and skills training and approved seagoing service of which not less than 30 months is in the engine department;

o 1/3 of sea service shall be on vessels of 750 kW or more propulsion power.

□ Completed approved education and training meeting competences of A-III/6 of STCW Code; o Approved training course

□ Meet the standards of competence in A-VI/1, Par. 2; Section A-VI/2 Par. 1-4; Section A-VI/3, Par. 1-4; and Section A-VI/4, par. 1-3 of the STCW Code o Approved training courses



□ Safety Familiarization Training □ Advanced Firefighting □ Basic Safety Training □ Electro-Technical Officers Course □ Proficiency in survival craft □ Proficiency in medical first aid+ □ Security Awareness Training □ Security Training for Seafarers with Designated Security Duties (if

applicable)


SPECIAL TRAINING REQUIRED FOR CERTAIN TYPES OF SHIPS REG: V/I

Masters, Chief Engineers, Chief Mates, 2nd Engineer and persons with immediate Responsibility on Tankers

LEVEL: OPERATIONAL

General Requirements Training Requirements (Submit copies of training certificates)

□ Sea service: Have at least 3 months sea service on tankers, OR

□ Min. 1 month supervised sea service on < 3,000 GT tanker with less than 72 hour voyage durations and knowledge gained equal to that of a normal 3 mth service AND

□ Appropriate experience to type of tanker served.

□ Advanced Tanker or Tanker PIC course appropriate to DL, Chemical

or DG

CDMP-5000-E Rev01

REG: V/2

Masters, Chief Engineers, Chief Mates, 2nd Engineer and persons with immed. Responsibility on Passenger Vessels

LEVEL: OPERATIONAL


□ Assigned immediate responsibility for embarking/disembarking pssgrs, loading/ discharging/securing cargo, or closing hull openings must complete approved training in:

o Passenger Safety, Cargo Safety and Hull Integrity specified in A-V/2, par. 4

□ Having responsibility for safety of passengers in emergency situations must complete approved training in Crisis Management and Human Behavior specified in A-V/2 par. 5

□ Passenger Safety □ Cargo Safety □ Hull Integrity □ Crisis Management and Human Behavior

REG: V/I

Officers and Ratings on Tankers LEVEL: SUPPORT


□ Sea service: Have at least 3 months sea service on tankers, OR

□ Complete an approved tanker familiarization course mting A-V/1, OR

□ Min. 1 mth supervised sea service on < 3,000 GT tanker with less than 72 hour voyage durations and knowledge gained equal to that of a normal 3 mth service

□ Tanker Familiarization course

REG: V/2

Officers and Ratings and other personnel on Passenger Ships LEVEL: OPERATIONAL

General Requirements □ Designated on muster lists to assist passengers

with emergency situations must complete Crowd Management training spec. in A-V/2 par. 1 prior to being assigned duties

□ Having specific duties on board, must complete vessel familiarization training specified in A-V/2 par. 2 prior to being assigned duties

□ Providing direct services to passengers must complete training in communication and life-saving procedures specified in A-V/2 par. 3

Training Requirements (Submit copies of training certificates) □ Crowd Management Training □ Vessel Familiarization □ Communication □ Life-saving procedures

CDMP-5000-E Rev01

COMMONWEALTH OF DOMINICA Office of the Maritime Administrator

PHYSICAL EXAMINATION REPORT/CERTIFICATE

This form must be completed by a licensed physician. LAST NAME OF APPLICANT

FIRST NAME MIDDLE INITIAL

DATE OF BIRTH DAY MONTH YEAR

PLACE OF BIRTH CITY COUNTRY

SEX � MALE � FEMALE

EXAMINATION FOR DUTY AS: Master Mate Engineer Radio Officer Rating

� � � � �

MAILING ADDRESS OF APPLICANT:

MEDICAL EXAMINATION (See Page 2 for medical requirements) STATE DETAILS ON Page 2 HEIGHT WEIGHT BLOOD

PRESSURE

PULSE RESPIRATION GENERAL APPEARANCE

VISION: RIGHT EYE LEFT EYE WITHOUT GLASSES / WITH GLASSES /

HEARING: RT. EAR

LEFT EAR

COLOR TEST TYPE: BOOK � LANTERN � CHECK IF COLOR TEST IS NORMAL – YELLOW RED GREEN BLUE HEAD AND NECK HEART (CARDIOVASCULAR)

LUNGS SPEECH (DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER)

IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?

EXTREMITIES: UPPER LOWER

IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY, OR TO RENDER HIM UNFIT FOR SERVICE AT SEA OR LIKELY TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD?

Signature of Applicant Date THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN. THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO : ______________________________________________________

Name of Applicant

(HE) (SHE) IS FOUND TO BE (FIT) (NOT FIT) FOR DUTY AS A: (MASTER, MATE, ENGINEER, RADIO OFFICER OR RATING) NAME AND DEGREE OF PHYSICIAN ADDRESS NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY DATE OF ISSUE OF PHYSICIAN’S CERTIFICATE SIGNATURE OF PHYSICIAN _____________________________________________ ________________________________

Date

This certificate is issued by authority of the Maritime Administrator and in compliance with the requirements of the Medical Examiner (Seafarers Convention 1946 (ILO NO. 73))

CDMP-5000-E Rev01

MEDICAL REQUIREMENTS All applicants for an STCW’95 Certificate of Competence, Seafarer’s Identification Document and a Dominica Training Record Book or certification of special qualification shall be required to have a physical examination reported on this Medical Form completed by a certificated physician. The completed medical form must accompany the application for Certificate of Competence, application for seafarer’s identity document, or application for certification of special qualifications. This physical examination must be carried out not more than 12 months prior to the date of making application for a Certificate of Competence, certification of special qualifications, or a seafarer’s book. Such proof of examination must reestablish that the applicant is in satisfactory physical condition for the specific duty assignment undertaken and is generally in possession of all body faculties necessary in fulfilling the requirements of the seafaring profession. In addition, the following minimum requirements shall apply: 1. All applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered voice in the better ear at 15 feet and in the poorer ear at 5

feet. 2. Deck officer applicants must have (either with or without corrective lenses) at least 20/20 vision in one eye and at least 20/40 in the other. If the applicant uses

corrective lenses, he must have vision without corrective lenses of at least 20/160 in both eyes. Deck officer applicants must also have normal color perception and be capable of distinguishing the colors red, green, blue and yellow.

3. Engineer and radio officer applicants must have (whether with or without corrective lenses) at least 20/30 vision in one eye and at least 20/50 in the other. If the applicant wears glasses, he must have vision without glasses of at least 20/200 in both eyes. Engineer and radio officer applicants must also be able to perceive the colors red, yellow and green.

4. An applicant’s blood pressure must fall within an average range, taking age into consideration. 5. Applicants afflicted with any of the following diseases or conditions shall be disqualified: epilepsy, insanity, senility, alcoholism, tuberculosis, acute venereal

disease or neurosyphilis, AIDS and/or the use of narcotics. 6. Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired for normal voice communication. 7. Applicants for able seaman, bosun, GP-1, ordinary seaman and junior ordinary seaman must meet the physical requirements for a deck/navigational officer’s

certificate. 8. Applicants for RFPEW, fireman/watertender, oiler/motorman, pumpman, electrician, wiper, tankerman and survival craft/rescue boat crewman must meet the

physical requirements for an engineer officer’s certificate.

DETAILS OF MEDICAL EXAMINATION (To be completed by examining physician)

IMPORTANT NOTE: The original copy of the physical report must accompany the application. A duplicate copy clearly labeled ‘certified copy’ on its face and initialed by the examining physician must be maintained by the applicant as evidence of physical qualification while serving on board a vessel.