Dc Endorsement Form – Fill Out and Use This PDF

	Application for issuance of certificate (Endorsement)									Page 1 of 2
	For Service on Tankers by FCs.
	The Facilitation Centre. CMMI Chennai Chapter.
1		Applied for Tanker Oil/ Chemical/ Liquefied Gas				Date of Submission:
		( Note each category need separate application. Tick only the one type, what you applied for)
2 Personal particulars ( Fill capital letters only)
	a	NAME in capital
	b	Contact Number				e. Nationality
	c	Date of Birth				f. Place of Birth
	d	C D C No				g. INDos No
	d	Passport No
3		Modular courses	Certificate No	Level		Institute
		done detail
					Name	Location		Cont No		Email add
	a	Fire
	b	Oil Tanker
	c	Chemical
	d	Gas
4 Record of Service: On type of the tanker for which endorsement is sought. Not applicable for fresher's
		Vessel Particulars				Duration of Service
		Name		Port of Reg	Rank	From		To		Total Served
	a
	b
	c
	d
	e
5		Declaration:
	a I hereby declare the that the particulars given in this application are true to the best of my knowledge.
	b	I have read the instruction given overleaf
	c	I am aware that , if the given information found false, I am liable for punishment under section 182
		Date:			Place			Signature of Applicant
6		Payment detail: Note the DD preferably from Indian Bank or any other nationalized bank only, payable at Chennai.
	a	DD drawn in favor of " P O, MMD Chennai for Rs. 1000/-
		DD No:			DD Date			Bank detail
	b	DD drawn in favor of " The Company of Master Mariners of India, Chennai Chapter" for Rs. 1124/-
		DD No:			DD Date			Bank detail
		……………………………………………………………………………………………………………………………………
7		Payment receipt (Fill up all, except Signature))			CMMI Chennai Contact number :		72008 33279
		Your Application number……………………. Dated…………………..
		Received with thanks from Mr.…………………….. For the application process fees of Oil/ Chemical/ Gas tanker
		…………… Bank, DD no………………. For Rs.1000 for MMD fees & DD no………………… for Rs. 1124* for CMMI fees.
		( * Rs. 1000 + 12.36% service tax Rs.124)
		Date:				Sig of CMMI Authorized signatory.

Instruction for filling this application

Page 2 of 2

1Name should be written in CAPITAL LETTERS, and the way it should appear in your certificate

2 Your contact mobile number is must

3 Separate application with fees should submitted for Oil /Chemical/Gas

4 All photo copies and the print outs should be self attested with your signature at the bottom.

5 In the back side of the both DD , your name, contact number & CDC number should be written 6 Write your name at the back side of your passport size color photograph.

Attach following document as instructed in the same order.
Against each srl number put	or	mark

1Passport size photo - 3 numbers, your name written on back side 2 a DD drawn in favor of " P O, MMD Chennai for Rs. 1000/-

b This DD please be drawn, preferably from Indian Bank or any other nationalized bank

c On the back side of this DD, write your (i) Name, (ii) Contact number (iii) CDC number .

3 a DD in favor of " The Company of Master Mariners of India, Chennai Chapter" for Rs. 1124/- b This DD please be drawn, preferably from Indian Bank or any other nationalized bank

c On the back side of this DD, write your (i) Name, (ii) Contact number (iii) CDC number . 4 Copy of Fire prevention and Fire fighting course, STCW 1995 or 2010, self attested

5 Copy of Oil/ Chemical / Gas Taker familiarization STCW 1995 or 2010, self attested

Note: If the tanker course done on or after 1/1/2012, the DCE will be valid up to 31/12/2016. Other wise the DCE validity date will be 5 years from the completion of tanker course date.

6 e samundra screen shot copy, where your Sea service is recorded. Self attested. 7 CDC Copy, all stamped pages copy, self attested

8 Passport all stamped pages, self attested

9 Print out of Seafarer profile registration on DG Shipping web site.

10Medical fitness certificate, Valid at least 6 months from the date of application, in original

11Additional document required to attach, only incase of Renewal

a Original Old Level 1, DC Endorsement ( In case of renewal)

bOriginal letter issued by Owner of the vessel/agent regarding minimum of 3 months supervised sea service, with RSPL number

(In case of non availability of original letter, than fresh course on tanker familiarization need to be

done)

ce samundra (Form III A) screen shot copy, where your Sea service Sign IN & Sign OFF dates mentioned, with the company seal and signature

Application forms acceptance days:

Monday to Friday - 10 am to 4 pm ( Except National Holidays)

While submitting the application form, please bring all your original documents for verification.

Certificate collection date:

You can collect the certificate in 2 days, provided the verifications reaches us in time. We inform you through phone, once your certificate is ready

Facilitation centre Chennai

Contact mob no: 72008 33279. (Check the status before reporting for collection.)

Email: cmmi.chennaicertificates@gmail.com