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Republic of The Philippines Department of Transportation and Communications STCW Office

1) The document is a screening form for Vincent Rojales' application for issuance of a Certificate of Proficiency (CoP) from the Philippine Maritime Industry Authority (MARINA). 2) It lists the documentary requirements for his application and whether they were submitted or not, including training records, sea service certificates, medical certificates, and photographs. 3) The form also acknowledges receipt of his application, lists the fees owed, and provides spaces for payment details and signatures from evaluators and cashiers processing his application.

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Heralynn Baloloy
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30 views

Republic of The Philippines Department of Transportation and Communications STCW Office

1) The document is a screening form for Vincent Rojales' application for issuance of a Certificate of Proficiency (CoP) from the Philippine Maritime Industry Authority (MARINA). 2) It lists the documentary requirements for his application and whether they were submitted or not, including training records, sea service certificates, medical certificates, and photographs. 3) The form also acknowledges receipt of his application, lists the fees owed, and provides spaces for payment details and signatures from evaluators and cashiers processing his application.

Uploaded by

Heralynn Baloloy
Copyright
© © All Rights Reserved
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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CERT No.

:04-04
Initial Issue Date: 09-19-2013 Appointment Date: Nov 13, 2015 Appointment Time: 12:00
Revision Date: 09-09-2014
Republic of the Philippines
Department of Transportation and Communications
MARITIME INDUSTRY AUTHORITY
STCW OFFICE

SCREENING FORM
APPLICATION FOR ISSUANCE OF CERTIFICATE OF PROFICIENCY

NAME OF SEAFARER ROJALES VINCENT SESIMA APPLICATION NO. 39-2014-71541


CELLPHONE 09062221280 E-MAIL ADDRESS [email protected]
ADDRESS 091HALAYHAY TANZA CAVITE 4108 COURSE TO APPLY:
- SDSD

SIGNATURE OVER PRINTED NAME OF SEAFARER / AUTHORIZED REPRESENTATIVE


Documentary Requirement
Submitted Not Submitted
(Please bring the original for verification)
A. Other COPs (Chapters V & VI)
1. Certified true copy of fully accomplished Training Completion of Records of Assessment (TCROA)
2. Certified true copy of Enrollment Report
3. Certified true copy of Training Certificates issued
4. Copy of filled-up SIRB pages (including 1st page) for courses requiring sea service
5. Certificate of Sea Service from Manning/Shipping Co. (in MARINA prescribed form)
6. Copy of Valid Medical Certificate issued by DOH Accredited Medical Clinic
7. For Manning/MTIs: 2 copies ID Pictures taken within last 6 months, passport size, in white background in
appropriate uniform in soft copy (USB or CD), as applicable
B. For Watchkeeping NEW RENEWAL
1. Photocopy of COP on Basic Safety
2. Certificate of Sea Service from Manning/Shipping Co. (in MARINA prescribed form)
3. Copy of filled-up SIRB pages for courses requiring sea service
4. TESDA Certificate of Competency (COC) (for renewal only) / Registry of ratings assessed and certified (New
Entrant)
5. Copy of Valid Medical Certificate issued by DOH Accredited Medical Clinic
6. For Manning/MTIs: 2 copies ID Pictures taken within last 6 months, passport size, in white background in
appropriate uniform in soft copy (USB or CD), as applicable
C. For Expedite processing, Certified True Copy of the following (in addition to the above requirements):
1. Letter Request
2. Valid Overseas and Employment Certificate (OEC)
3. Employment Contract
4. Air Ticket/Flight Details
Screen and Evaluated by: _______________________ Date/Time:
Signature over Printed Name
(Document Evaluator) CASHIER'S USE ONLY
O.R. No.: _______________________
Action Taken/Remarks: ____________________________ Date: ___________ Amount _________

ACKNOWLEDGEMENT

Name of company/applicant: ROJALES VINCENT SESIMA Date filed: NOVEMBER 05, 2015

This is to acknowledge receipt of your application for ISSUANCE OF CERTIFICATE OF PROFICIENCY with assigned APPLICATION NO. 39-2014-71541

Rest assured that subject application shall be acted upon by the appropriate office/s of this Agency.

Document Evaluator: __________________________ DATE/TIME OF RELEASE: ______________________________


Signature over Printed Name

AUTHORITY TO ACCEPT PAYMENT

APPLICATION CONTROL NO. 39-2014- 71541


NAME OF COMPANY/APPLICANT: ROJALES VINCENT SESIMA
Item No. of Pcs Amount
Issuance / Renewal of CoP/s
Expedite CoPs
Certified True Copy
TOTAL P
Document Evaluator ____________________________ Date/Time: ______________________
Signature over Printed Name
CASHIER'S USE ONLY:
O.R. No.:
Date/Time

_______ Cash Payment received by:


Mode of Payment: _______ Check No.________ (Cashier's Printed Name &
Date Issued __________ Signature)

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