Form F3103 Es PDF Details

Navigating through the intricacies of marine licensing in Queensland requires familiarity with various forms, among which the F3103 Es form is pivotal. This comprehensive document serves multiple purposes for individuals engaged in maritime operations, including applications for Certificate of Competency, Amendments of a Marine Licence, STCW95 Endorsements, Certificate of Recognition, Revalidation of a Marine Licence, and even simplifies processes like Change of Address. To complete the application successfully, one must provide current photographs, detailed personal information, and specifics about any previously held marine licenses. Additionally, the form mandates declarations regarding medical fitness, eyesight certificates, and a record of practical experience at sea. Ensuring accuracy and completeness when filling out this form is critical, as it is directly tied to the legality and validity of one’s marine operations. The detailed instructions and requirements outlined on the form guide applicants through each step, making sure they meet all prerequisites for their specific needs, whether it's obtaining a new licence or updating existing credentials. Privacy considerations are also taken into account, with assurances that personal information is protected according to law, highlighting the form's comprehensive approach to managing marine licensing requirements in Queensland.

QuestionAnswer
Form NameForm F3103 Es
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namespdf_marine_lice nce_app msq f3103 form

Form Preview Example

Marine Licence Application

(See notes on page 3)

This application is for: (please tick P one box)

Certificate of Competency

 

 

 

Amendment of a Marine Licence

 

 

STCW95 Endorsement Review

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change of Address

 

 

 

Certificate of Recognition

 

 

 

Revalidation of a Marine Licence

 

 

 

 

 

 

 

 

 

 

 

 

Please note— Current photographs are required for these applications.

 

 

 

 

 

Class of licence for which this application applies

 

 

 

 

 

File number (if known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant's details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family name (please PRINT)

 

 

 

 

Given name/s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postal address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postcode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential address (if the same postal address write "as above")

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postcode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact phone number

 

 

 

Mobile phone number

 

 

 

 

E-Mail address

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height

 

 

Eye colour

 

Hair colour

Gender

 

 

 

 

 

cm

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver Licence number / CRN (Customer Reference Number)

Place of birth (Town, State, Country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

/ /

Particulars of Marine Licences held

Number

Grade

Issuing authority

Date issued

Expiry date

Endorsements

Ever suspended or cancelled (state why)

Record of Service Book

Date issued

 

Place issued

Official book number

/

/

 

 

 

 

 

 

 

 

 

Record of Practical Experience at Sea (ROPES) book

 

Date issued

 

Place of issue

Official book number

/

/

 

 

 

 

 

 

 

 

 

 

Workplace based task book details (issued by RTO)

Date issued

Place of issue

Official book number

/ /

Notification of Sea Service Assessment

Date of assessment Qualification level

/ /

Details of Eyesight Certificate (Original certificate to be sighted)

Date issued

 

Doctor / optometrist

/

/

 

 

 

 

 

 

Certificate of Medical Fitness (Original certificate to be sighted)

Date issued

 

Doctor

/

/

 

 

 

 

 

 

Contact phone number

()

Contact phone number

()

Applicant’s declaration:

 

I (please PRINT)

hereby declare that the particulars entered in this application are true and correct to

the best of my knowledge and belief, and that the documents submitted with this application are true and genuine documents signed by the persons whose name/s appear on them. I make this declaration knowing that it is an offence under the Transport Operations (Marine Safety) Act 1994 for a person to give to the Chief Executive, the General Manager or an officer of the department or of Maritime Safety Queensland, a document containing information the person knows is false or misleading in a material particular. Maximum penalty $15,000.

Applicant’s signature

Witnessed by (please print)

Witness signature

Date

/ /

<Two (2) current passport size identical colour photographs must be supplied and attached to page 3 of this application

<Two specimen signatures are also required on page 3

Form F3103_ES V01 09/10

Forms Management Unit

Page 1 of 3

 

Marine Licence Application continued ... page 2 of 3

This page is for Office Use Only

Training

Evidence

Training provider

Date

Sighted

Assessor’s notes (Sighted and verified)

ROS Book

Notification of Sea Service Assessment (copy attached) issued at—

ROPES Book On—

/ /

Workplace task book

Examination results

 

Pass/

Examiner’s

Date

Exam centre

Resit

Pass/

Examiner’s

Exam centre

 

Fail

initials

date

Fail

initials

 

 

 

 

 

 

 

 

 

 

 

 

 

Deck oral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Engineering oral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessor's declaration

 

 

 

 

 

 

 

This candidate has met all requirements for the issue/ revalidation/ amendment (delete as required) of a certificate of competency/ recognition (delete as required) as—

The relevant oral assessment form has been completed. A copy of the relevant Certificate issued under TDM07, or copies of Statements of Attainment for completed competency-based units under TDM01, is/are attached to this application. Being a delegated officer under section 102(1) Transport Operations (Marine Safety) Regulation 2004 to conduct such assessments/ examinations, I recommend that the Certificate of Competency/ Revalidation be issued/ amended.

Marine assessor’s name (please PRINT)

 

Date

 

Stamp

 

 

 

 

 

/

/

 

 

 

 

 

 

Signature

 

Centre

 

 

 

 

 

 

 

 

 

 

 

 

Receipt number

Receipt date

Amount

Examination centre

Temporary authority issued

/ /

Yes

No

Number

Date issued

Copy attached

/ /

Head Office Use Only

 

 

Entered to MLS on

Data Entry Open Initials

MLS Certificate number

/ /

Date posted

Checked/Authorised by

/ /

Form F3103_ES V01 09/10

Forms Management Unit

Page 2 of 3

Marine Licence Application continued ... page 3 of 3

Guide to completing this application

Application for Certificate of Competency

•Fully complete page one of this application and Applicant’s Declaration.

•Notification of Sea Service Assessment.

•Provide two specimen signatures in the boxes provided below making sure the signatures are completely inside the boxes provided.

•The following must be lodged with this application:

-Two (2) passport size photographs (see note on photographs below).

-Provide a current Certificate of Medical Fitness including an eyesight test as defined in Medical Fitness Standards (USL Schedule 1) valid for 2 years.

-Proof of Identity (please obtain and refer to form F4362).

•Other prerequisites relevant to the class of licence as described in Notes for the Guidance of Candidates.

•Pay the prescribed fee (the fee is subject to change).

Application for a Certificate of Recognition

•Complete page 1 and the "Applicant's declaration".

•Provide two specimen signatures in the boxes provided below making sure the signatures are completely inside the boxes provided.

•Two (2) passport size photographs (see note on photographs below).

•A copy of the original licence certified by a Justice of the Peace, Commissioner of Declarations or official of a Marine Authority or other official should accompany this application.

•Pay the prescribed fee (the fee is subject to change).

Application for Amendment/Renewal of a Marine Licence

•Complete pages of this application.

•Other prerequisites may apply (please contact your local Marine Operations Centre for further information).

•The original licence must accompany this application.

•Pay the prescribed fee (the fee is subject to change).

Application for Replacement

 

Evidence of Identity documents provided

 

You cannot use this form to obtain a replacement for a lost or damaged licence.

•

Document

Numbered

•

To apply for a replacement licence obtain and complete form F4292.

 

 

 

 

 

1.

 

•

You must prove your identity. Please obtain and refer to form F4362.

 

 

 

Please refer to evidence of identity on the said form.

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

Example only

 

 

 

 

 

 

Do not write outside the boxes

Specimen signature

 

 

 

 

 

45 mm

Specimen signature

Do not attach

photographs here

35mm

Photographs

•We require two (2) passport size identical colour photographs of you.

•The photographs should be a full front view of your head and shoulders without any head covering or tinted glasses and have a plain, light coloured background.

•The photographs must be less than 1 year old.

•Poor quality photographs and digital photographs will not be accepted.

Other Information

•Notes for the Guidance of Candidates for each grade of licence are available from your local Marine Operations Centre. Locations can be found at www.msq.qld.gov.au - “Contact Us”.

Privacy Disclaimer

The Department of Transport and Main Roads collect information on this form under the Transport Operations (Marine Safety) Act 1994 to manage the Queensland commercial licence registers. This information is accessible by authorised departmental officers and the Queensland Police Service. Information about commercial licence holders may also be disclosed to ship insurers, statutory entities, lawyers, insolvency entities, persons involved in ship accident/incidents, and to or through interstate licensing authorities. The Department of Transport and Main Roads will not disclose your personal details to any other third parties without your consent or unless required by law.

Form F3103_ES V01 09/10

Forms Management Unit

Page 3 of 3

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This document will require specific data to be filled out, so you should take the time to enter exactly what is asked:

1. To start with, once completing the Form F3103 Es, start out with the form section that contains the next blank fields:

Stage no. 1 for submitting Form F3103 Es

2. Once your current task is complete, take the next step – fill out all of these fields - Particulars of Marine Licences held, Number, Grade, Issuing authority, Date issued, Expiry date, Endorsements, Ever suspended or cancelled state, Record of Service Book Date issued, Place issued, Record of Practical Experience at, Place of issue, Workplace based task book details, Place of issue, and Notification of Sea Service with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part no. 2 for filling in Form F3103 Es

It is possible to make an error when filling out the Place of issue, therefore ensure that you reread it prior to deciding to send it in.

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