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GOC "STCW and GDMSS (Form D - Information Sheet) "

The document is an information sheet for applicants seeking radio operator licenses or training. It requests biographical information such as name, address, citizenship status, education history, employment history, and certification that all information provided is true. Applicants must provide details of any name changes and sign and date the document, swearing its truthfulness before a notary public. Incomplete or inaccurate applications may be grounds for denial of the application.

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743 views

GOC "STCW and GDMSS (Form D - Information Sheet) "

The document is an information sheet for applicants seeking radio operator licenses or training. It requests biographical information such as name, address, citizenship status, education history, employment history, and certification that all information provided is true. Applicants must provide details of any name changes and sign and date the document, swearing its truthfulness before a notary public. Incomplete or inaccurate applications may be grounds for denial of the application.

Uploaded by

vhanflaminian
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NATIONAL TELECOMMUNICATIONS COMMISSION Form “D”

Radio Regulations and Licensing Department


RADIO OPERATOR’S AND TRAINING SCHOOLS DIVISION
INFORMATION SHEET

INSTRUCTIONS: 1. Print all data with your own HANDWRITING. WRITE LEGIBLY
2. If question is not applicable write “NA”
3. Any deliberate omission or distortion of material facts may give sufficient cause for denial of application

NAME:
LAST NAME FIRST NAME MIDDLE NAME ALIAS
PRESENT EMPLOYMENT
HOME ADDRESS
TELEPHONE NO.
CHANGE IN NAME, (if by court, give details)
DATE OF BIRTH: PLACE OF BIRTH:
CITIZENSHIP IF NATURALIZED, STATE PREVIOUS CITIZENSHIP, COUNTRY
AND NATURALIZATION CERTIFICATE NUMBER
DESCRIPTION MARITAL STATUS (Single/Married/Separated/Widow/widower)
SEX NAME OF SPOUSE
HEIGHT OCCUPATION/EMPLOYER
WEIGHT
NAME OF FATHER OCCUPATION
NAME OF MOTHER OCCUPATION
NAME OF BROTHER(S) NAME OF SISTER(S)

PLACES OF RESIDENCE SINCE BIRTH


LOCATION INCLUSIVE DATES

SCHOOLS ATTENDED SCHOOL NAME LOCATION INCLUSIVE DATES

SECONDARY

COLLEGE
POST GRADUATE
PREVIOUS EMPLOYMENTS
NAME OF EMPLOYER LOCATION POSITION INCLUSIVE DATES

I HEREBY CERTIFY THAT THE FOREGOING ARE TRUE AND CORRECT to the best of my knowledge and belief and I agree that
any MISTATEMENT OR OMISSION AS TO THE MATERIAL, FACTS will constitute ground for immediate denial or cancellation of my
application.

Signed at _____________________ Date_________________________

_________________________________________
(NAME AND SIGNATURE OF APPLICANT)

SUBSCRIBED AND SWORN BEFORE ME, a Notary Public, this __________th day of ___________________________
Affiant having exhibited his/her Res. Cert. No._________________________ issued at ___________________________
On ____________________________________

Doc. No. _________


Page No. _________
Book No. _________
Series of _________
_________________________
NOTARY PUBLIC

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