Xene

| APPLICATION FOR A QUALIFYING SEA SERVICE ASSESSMENT
Marine Safety (Domestic Commercial Vessel) National Law Act 2012, Schedule 1 |

This application should be completed by applicants who are applying for a first time issue or other renewal (revalidation) of a Certificate of Competency.
Submitting this form does not indicate acceptance of qualifying sea service. The final decision on qualifying sea service is made by the National Regulator or the delegate of the National Regulator.
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A. Applicant’s details (complete all boxes)
Title (Mr/Mrs/Ms/Dr) Family name* Given names
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*Your family name will appear after your given names on your certificate
Date of birth Place of birth (town, state, country) Nationality
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If not an Australian citizen, are you a permanent resident? Yes     No
Residential address
Street number and name      | Town/suburb      | State      | Postcode      |
Postal address (if different from above)
PO Box/Street number and name      | Town/suburb      | State      | Postcode      |
Contact numbers
Home phone      | Business phone      | Mobile      | Email      |

Note: Proof of Identity must be provided with this application.

B. Certificate(s) applied for
Complete this section for the Certificate(s) of Competency for which this qualifying sea service application is being applied for and provide either the original evidence of sea service claimed (if lodging in person) or a certified copy (if lodging by post).  
Certificate | Class/Grade | Taskbook number | Details of restrictions applied for | Details of endorsements applied for |
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C. Other Certificate(s) currently held
Complete this section for Certificate(s) of Competency held in addition to the certificate(s), for which...