certificate no. application for ship’s cook certificate

1 Personal Details

of 3

Date of Birth (DD/MM/YYYY): Nationality:

Gender: MaleNational Identity No. (Passport):

Surname/Family Name:Given Name(s):

Female

SHIP’S COOK CERTIFICATEAPPLICATION FOR

New:

Renew:

Replacement of lost:

Replace. of damage:

Application Type

Personal Details1

2 Details Of Qualifications Held

If Yes please provide the following details below:

Do you hold a Certificate as a Ship’s Cook?

Certificate Number:Certificate Issued by:

Date of Expiry (DD/MM/YYYY):Date of initial issue (DD/MM/YYYY):

Ship’s Cook Qualifications:2

Yes No



Date of Expiry (DD/MM/YYYY):Qualification Level:


Do you hold a professional qualification as a Cook/Chef?

Name of Certificate / Degree/ Diploma:

Issued by (Name of Issuing Establishment):

Professional Qualifications:2.1

Do you have evidence of food hygiene and handling qualifications?

Yes No

Yes No

If Yes please provide details below:

Do you have previous experience as a Ship’s Cook/Chef?

Experience as a Ship’s Cook/Chef:2.2

Yes No

For official use

Certificate no.

SID no.

For official use

Insert photo

MOC/MTD/SCC-APP

of 3



Date of Expiry (DD/MM/YYYY):Qualification Level:

Do you have evidence of food hygiene and handling qualifications? Yes No

Do you hold: Personal Survival Techniques (STCW Table A-VI / 1-1)

STCW Certification:2.3

Yes No

Basic Fire Prevention and Firefighting (STCW Table A-VI / 1-2) Yes No

Elementary First Aid (STCW Table A-VI / 1-3) Yes No

Personal Safety and Social Responsibilities (STCW Table A-VI / 1-4) Yes No

Issued on behalf of (Country):Certificate Number(s):

Date of last refresher training (DD/MM/YYYY):Date of initial issue (DD/MM/YYYY):

Do you hold: Yes NoSecurity Awareness (STCW Section A-VI / 6)

Issued on behalf of (Country):Certificate Number(s):

Date of last refresher training (DD/MM/YYYY):Date of initial issue (DD/MM/YYYY):

Give details of Seafarer Medical Fitness Certificate held:

Date of Issue (DD/MM/YYYY): Date of Expiry (DD/MM/YYYY):

Issuing Authority (Country):

3 Medical Fitness Certification:

Certificate Number(s):

4 Declarations

Declaration by applicant

I, the undersigned, declare that the information I have given is, to the best of my knowledge, true, correct and complete. I also declare that thecopies of the documents submitted are true copies of genuine documents.

Name: Date (DD/MM/YYYY):

Signature

Date (DD/MM/YYYY):

Declarations by Company

I, the undersigned, declare that the applicant described in this application and whose documents, or copies, are attached is proficient to act asa ship’s cook on a Kuwaiti vessel.

Name:

Position:

Signature

Company's stamp

of 3

5 Checklist of Essential Documents and Actions

DOCUMENT OFFICIAL USE ONLY

Professional Qualifications

Tick (if enclosed

or confirmed)

Food hygiene and handling qualifications

Evidence of experience as a Ship’s Cook

Passport

Medical Fitness Certificate

Signed Declaration by Applicant (Section 4)

Signed Declaration by Company / Agent sponsoring the application

STCW Basic Training Certificate of Proficiency / Refresher Certificates (as applicable)

Please ensure that you read and understand these notes before completing the form. ے

considered acceptable for service onboard Kuwaiti ships. Such certificates should be issued in accordance with Regulation I/9 of STCW.by, a Medical practitioners accredited by a state authority that has ratified or is a party to either the STCW Convention or the MLC 2006. - Medical Fitness Certificates are required to be valid for a minimum period of six months at the time of application. Medical certificates issued

- Dates should be given in the format DD/MM/YYYY, e.g. 19 September 1972 should be written as 19/09/1972.

format as appears in the applicant’s passport.

- Enter the applicant’s personal details in the boxes provided. The applicant’s name should be given in FULL and should be given in the same

and stamped by the authorized signatory.

- Please enclose copies of all documents necessary to establish your eligibility for a Ship’s Cook Certificate. All documents submitted are signed

application enter NIL.- Please complete this form electronically in ENGLISH, print and sign then submit the application. If a section is not relevant to your