Certificate of Sea Service PRC Form

NOT FOR SALE

MDO Form No. 3 Rev. 01/11-04-200 Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION Manila

BOARD OF MARINE DECK OFFICERS CERTIFICATE OF SEA SERVICE (All statements herein are subject to verification)

TO THE BOARD OF MARINE DECK OFFICERS: THIS CERTIFIES that _____________________________________________ had actually serve our  supervision on board _________________________, __________________ of _______________________  (Name of Vessel)

(Type of vessel)

(State of Nationality of Vessel)

with Registry No. : _________ a _______________ vessel of _________ KW and _________ gross tonnage (Near Coastal/Seagoing) for a period of _________________________ _________________________________ ________ from _________________________ _________________________ to _________________  (No. of years) (Months) (Months) (Days) (Date of Embarkation) Embarkation) (Date of Discharge) Discharge) as ____________________. ____________________.

(Position Held) This certifies further that the above-stated data are all true and that any false statement/s made therein shall be ground for criminal prosecution.

Issued this _______________day of _______________20 ______at ____________________.

SEAL OF VESSEL SEAL OF COMPANY

 __________________________  _______________________________________ _______________ __  Name and and Signature of Port Captain/Pe Captain/Personnel rsonnel Mgr. Mgr.  __________________________  _______________________________________ _______________ __  Name of Local Local Shipowner Shipowner or Managing Managing Agent Agent Address : _______________________ _________________________________  __________   _________________________  _________________________________  ________ 

 ____________________________  ___________________________________  _______  MASTER  –   –  Signature Above Printed Name Nationality : _______________  _______________  Kind of License License : _______________  _______________  Registration Registration No. : _______________  _______________  Date of Registration Registration : _______________  _______________  Expiry Date : _______________  _______________ 

Telephone Nos. __________________________ ____________________________  __ 

SUBSCRIBED AND SWORN TO before me this __________day of ______________,20 ______________,20 ______, at  ________________________.  ________________________.

Doc. No. Page No. Book No. Series No.

: _______________  _______________  : _______________  _______________  : _______________  _______________  : _______________  _______________ 

 Note : This This form is good only for one (1) vessel. This form can be reproduced. Any erasure/obliteration may be a ground for denial.