MSF 4275
-----------------------------------------------------------------------------------------------------------------------------------------APPLICATION FOR AN ORAL EXAMINATION LEADING TO THE
ISSUE OF A CERTIFICATE OF COMPETENCY (STCW) FOR
Engineer Officers in the Merchant Navy
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1. PERSONAL DETAILS
Title: MR
Nationality: INDIAN
National Identity Number: PUT YOUR PASSPORT NUMBER
Full Home Address: MENTION THE ADDRESS WHERE YOU ARE STAYING
Address for return of documents: IF COURIER SERVICE IN THE AREA WHERE YOU ARE STAYING IS NOT
RELIABLE, PLEASE PUT AN ALTERNATIVE ADDRESS HERE OF SOME BIG CITY SO THAT YOUR COURIER
DOES NOT GET SENT BACK TO UK BECAUSE OF NON DELIVERY. IF THE COURIER SERVICE IN YOUR HOME
ADDRESS IS GOOD, LEAVE THIS SECTION BLANK.
2. CERTIFICATE APPLIED FOR
Second Engineer
III/2
Unlimited
None
Motor
\/
Leave the SDS Number blank on the bottom right hand corner of the page.
3. SEA SERVICE
Vessel Name: Only vessels after Class 4 CoC have to be put. Ships name can be written latest to earliest
from top to bottom or vice versa.
IMO Number: Check the IMO number on the ship stamp and put it on the form. If the IMO number is
missing, you can put the Official Number of the ship as well.
Flag: Indian, Panama, Liberian, Singapore, etc.
Reg. Power (KW): Put the Maine Engine power
S/M: Motor
Type: Container / Bulk Carrier / Tanker / Ro Ro
4. CHECKLIST
Put your Class 4 / Class 5 / MEC3 CoC Certificate No., Capacity and Country of Issue in this section.
4A FOR ALL APPLICANTS
Attested copy of Passport (\/)
CDC and Sea Service Testimonials (\/)
Two Passport Size Photographs (\/)
Valid Medical Fitness Certificate (\/)
Please note that the Medical Fitness Certificate has to be in the ILO147 format from a DG Shipping
approved doctor. You may contact your shipping company doctor for the same. If your earlier medical
fitness certificate (that you used for joining your last ship) is still valid for the next 6 months, then you do
not need to get a new medical fitness certificate.
2 photographs size 40 mm x 50 mm required with white background. Behind one photograph, please
write your name in CAPITAL LETTERS and your DATE OF BIRTH. Behind the other photograph, please
write your name in CAPITAL LETTERS. Then the person who has countersigned in section 6 of the NOE
form needs to write “ I CERTIFY THAT THIS IS A TRUE LIKENESS” and sign behind the photograph.
4B APPLICATIONS FOR A FIRST UK CERTIFICATE OF COMPETENCY
Leave this section blank. It is for applicants who are applying for a Class 4 (EOOW) CoC.
4C APPLICATION FOR A SUBSEQUENT CERTIFICATE
MNTB / MCA Approved UK academic qualifications …………… (\/)
Put a tick mark if you hold a BE Marine / Mechanical certificate and have obtained a NARIC LoC to be
eligible for exemptions.
5. YOUR SIGNATURE AND DECLARATION
Put your signature in the rectangular block. Make sure that the signature does not go outside of the box
as this signature will be embossed on your CoC. Put the date on which you have signed on the form.
In the rectangular block mentioned “for office use only”, do not write anything and do not paste your
photograph over there.
6. COUNTER SIGNATURE
Somebody who knows you in a professional relationship but is not your friend or relative needs to fill up
and sign in Section 6 of the form. This person also needs to sign behind one of the photographs. This
person could be a Captain, Chief Engineer, Superintendent, Doctor, Lawyer, Police Officer, School /
College teacher, etc.
7. PAYMENT
Click on the payment option Cheque / Bankers Draft (\/)
If you are making a payment by Credit Card, please fill the card details in the NOE form. You will also
need to sign below on the form. If the payment is made by a Demand Draft, do not sign on the form.
Payment for the NOE is 201 GBP and the DD is to be made in favour of
“THE MARITIME AND COASTGUARD AGENCY”.