APPLICATION FOR REVALIDATION OF CERTIFICATE OF COMPETENCY

1. NAME. : D.O.B. :

2. INDOS No. : CDC No. : PP No.:

3. COC (Grade) _______________________ No. _________________________ Date of issue:____________________

4. Phone No. _______________________ Mobile _______________________ E-mail ID ______________________
Address:____________________________________________________________________________________________

Additional Certificates Number Date of issue Issuing Authority

Medical Fitness Certificate
Revalidation Course
GMDSS GOC
STWC Endorsement on GMDSS

4.SEA SERVICES FOR THE LAST FIVE YEARS (Attach copy of CDC and service record duly authenticated by employer) :
Name of Ship GT Trade Type of Ship Capacity From To Period
Y M D

5. Details of service performed other that on board ships during ships last 5 years giving period of service, designation, nature of
duties, name address & contact of employer (attached employer Certificate)

6. Did any of the ships mentioned in para 4 suffer any causalities during your service on board ? If so, give details of date, time and
nature of casualty.

7. Did u undergo any inquiry by any Government or other Authorities in connection with your serice on board ships mentioned in
para 4 ? If so, give details of date, place, name of Authority and nature of inquiry.

8. A fees Rs. 2,500 for Revalidation of Certificate of Competency has been deposited ( receipt attached )
9. There copies of 30 mm x 25 mm size colour photographs.

I hereby declare that the information given above is correct and true to the best of my knowledge and belief.

Date:
Signature of Applicant.

Note : Any person who makes any false representation or knowingly givens any false information is liable for punishment of cheating
under section 182 and 420 of Indian Penal Code and revalidation certificate issue on such information will be withdrawn forthwith.

Specimen
Signatures

( FOR OFFICE USE ONLY)

The Eligibility of the candidate for issuing of revalidation endorsement was scrutinized in accordance with the guidelines and found to be in order.
*The certificate of competency revalidate until
Date:
 EXAMINER OF MASTER & MATES

MERCANTILE MARINE DEPARTMENT

MUMBAI / KOLKATA / CHENNAI.

*Copy of endorsement-annex II shall be forward to chief examiner of master and mates within 7 days from the date of Issuance