Fillable OLSI01 A10 98

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OLSI01 A10 98

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form ol/sI1
APPLICATION FOR
SEAFARER DOCUMENTS
FORM TO BE SUBMITTED IN DUPLICATE
REPUBLIC OF VANUATU
PORT VILA, VANUATU
This Document must be filled in completely and legibly in order to have documents issued.
I. Reason for Application
SEAFARERS ID BOOK LICENSE/ENDORSEMENT (Check both boxes if applying for both documents)
Check one: NEW RENEWAL TANKER ENDORSEMENT
REPLACEMENT / /Reason for Replacement
VESSEL NAME: ______________________________ OFFICIAL NUMBER: ___________
D
ESIGNATE ALL LICENSES OR ENDORSEMENTS BEING APPLIED FOR BELOW:
Master Chief Officer Navigating Officer of the Watch
REO (Electronics)
Chief Engineer 2nd Engineer Engineering Officer of the Watch
GOC
Able Seaman AB/LB Ordinary Seaman
ROC
Motorman Lifeboatman RTO (telephony) / RMO Other
MODU DOCUMENTS
OIM Barge Supervisor Ballast Control Operator Maintenance
Supervisor
II. Personal Information
Last / Family / Name (Surname)
Middle Name
Date of Birth (DD/MM/YY)
First / Given Name Place of Birth (City & Country) Citizenship
Height
Ft / Cm
Weight
Lb / Kg
Hair Color Eye Color
Male Female
Distinguishing Marks (Scars, Tattoos, Birthmarks, etc.):
Permanent Address
Mailing Address for Seaman’s Documents
Person to Notify in Case of an Emergency
Relationship to You
Address & Telephone Number of Person
P
LEASE STAPLE OR GLUE
PICTURES HERE
AT LEAST TWO (2) COLOR PICTURES
MUST
ACCOMPANY THIS APPLICATION.
Form OL/SI (02/09) Page 1 of 4
PRINT
CLEAR
Form OL/SI (02/09) Page 2 of 4
III. Description of Highest Grade License/Endorsements
LICENSE /
ENDORSEMENT
G
RADE
L
ICENSE NUMBER
I
SSUE
DATE
E
XPIRATION DATE ISSUING COUNTRY
Vanuatu
Foreign *
National
*
COMPLETE FOLLOWING INFORMATION AS PER YOUR NATIONAL CERTIFICATE
CAPACITY FUNCTIONS LEVEL** LIMITATIONS
*ATTACH COPIES OF OTHER LICENSES OR ENDORSEMENTS
** M = Management / O = Operational / S = Support
Have you ever been denied mariner documents by any other flag?
Yes No
Have you ever had any license issued to you revoked or suspended?
Yes No
Have you ever been convicted of a crime?
Yes No
(If
YES to any of the above, attach a full explanation of the circumstances and outcome to this application)
IV. SEA SERVICE
Notes:
1. List all vessels you have served on in the past 5 years.
2. Proof of sea service must be from seaman’s book or certificates of service. Copies are accepted.
3. If additional space is needed, attach additional pages.
Service
Vessel GRT
Power
HP / kW
Flag Rank
to from
Total
Time
V. General Education
DATES ATTENDED (MM/YY) SCHOOL SCHOOL
LOCATION
C
OURSE OF
STUDY
From To
D
EGREE (IF ANY)
VI. Nautical & Engineering Training
(Attach copies of ALL maritime training certificates)
DATES ATTENDED (MM/YY)
SCHOOL
S
CHOOL
LOCATION
C
OURSE
F
ROM TO
D
EGREE (IF ANY)
Form OL/SI (02/09) Page 3 of 4
VII. Declaration of Applicant
I, ______________________________________________________________________ hereby declare that:
Applicant Name
1. All information and supporting documents I have provided with this application are true, to the best of my knowledge.
2. I have read and understood Vanuatu Maritime Bulletin 108, “Legislation and Responsibilities”; and
3. I will abide by the Vanuatu Maritime Act and Regulations, the various conventions and mandatory codes addressed in
the Act and Regulations, and the regulations prescribed by all applicable International conventions and codes.
I understand that any information or attached document(s) found to be fraudulent in this application will nullify the
application and any documents issued thereof. I further understand, should the documents and information
provided herewith be found fraudulent, I will be prohibited from future employment on Vanuatu flag vessels, and
my name will be reported to other flag administrations.
Declared before me this _____ day of _____________
_______.
***Signature and Title of the Declarer
Signature & title of person authorized to take declarations
under the Maritime Act
VIII. Radio Operator Declaration
I, _______________________________________________________________________ hereby declare that:
Applicant Name
In connection with my service on board vessels registered under the laws and regulations of the Republic of Vanuatu, I
agree to:
1. Maintain secrecy in radio correspondence;
2. Refrain from unauthorized interception of radio communication not intended for public general use;
3. Refrain from disclosing the existence of any radio communication not intended for public general use; and
4. Conform to the regulations annexed to the International Telecommunications Union Convention in force, and all laws and
regulations of the Republic of Vanuatu applicable to the operation of ship radio stations.
Declared before me this _____ day of _____________ _______.
***Signature and Title of the Declarer
Signature & title of person authorized
under the Maritime Act to take declarations
*** Signatures can not be electronic.
Form OL/SI (02/09) Page 4 of 4
GENERAL INFORMATION AND INSTRUCTIONS
* * * * MISSING DOCUMENTATION WILL RESULT IN PROCESSING DELAYS AND / OR REJECTION OF THE APPLICATION. * * * *
Please read the following instructions carefully and enter all required information. This application may be completed
electronically; printed for signatures; and mailed to the Republic of Vanuatu along with all supporting documentation required.
APPLICATIONS
Application for Seafarer Documents – OL/SI 1
Medical Form - MED1
PHOTOGRAPHS
- Photos must be in color and portray a good likeness of applicant for satisfactory identification:
TWO (2) passport size (2”x 2”) photos
Facial front view of applicant
Taken no more than 1 year from the time application is submitted
Applicant’s name is to be printed on the reverse side of the photograph
IDENTITY DOCUMENTS
- One of the following is to be attached to the application:
Valid passport
Official, national “identity” document, recorded within one year of birth: Certificate of Identity; Birth or Baptismal Certificate;
Parish Record; Certificate of Naturalization
OTHER DOCUMENTS
A valid seaman’s document from another maritime nation, or
A letter of commitment of employment from a ship manager/operator for service onboard a merchant vessel.
TWO (2) LETTERS OF RECOMMENDATION
must be submitted regarding applicant’s character, sobriety, experience and
competency, one of which must be from a Master or Chief Engineer with whom applicant has served.
PROOF OF SEA SERVICE
(See Part IV of application)
PROOF OF NATIONAL LICENSE/ENDORSEMENT
- A certified copy of applicant’s national license and STCW endorsement, if
applicable.
PROOF OF GRADUATION
– A copy of a diploma from a nautical maritime or engineering academy, if applicable.
AGE AND CITIZENSHIP REQUIREMENTS
Applicants for navigating or engineering officers in charge of the watch, radio telephone operators, general operators, and
radio electronics officers must be at least 19 years of age.
Applicants for all other licenses must be at least 21 years of age.
Applicants may be of any nationality and need not be citizens or residents of the Republic of Vanuatu.
MISCELLANEOUS
- In the event approval of this application is not granted, a processing fee will be charged to the applicant, and
documents will be disposed of by Vanuatu.
RENEWAL APPLICATIONS
- In addition to the above requirements, a copy of the previously issued Vanuatu ID book or officer
license/endorsement must be included.
FEE SCHEDULE
- Payment must be made by check, money order, or wire transfer drawn on a US Bank and payable in US
dollars to Vanuatu Maritime Services Limited.
Seaman ID Book ........................................................................................................................................50.00
Master / Chief Engineer License / Endorsement / OIM / Ballast Control Operator...........................150.00
Chief Officer / 2ND Engineer / Maintenance or Barge Supervisor .....................................................125.00
All Other Officer Licenses / Endorsements including GOC / RTO / REO / RMO / ROC....................100.00
Renewal of License / Endorsement PRIOR to Expiration date...........................................................100.00
APPLICATIONS AND DOCUMENTS ARE TO BE SUBMITTED TO
Vanuatu Maritime Services Limited
39 Broadway, Suite 2020
New York, NY10006
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OLSI01 A10 98

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Completed 16 July 2020

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