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THE COMMONWEALTH OF DOMINICA

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THE COMMONWEALTH OF DOMINICA

    The Commonwealth of Dominica

    Office of the Maritime Administrator

    CDMP-5000

    Marine Personnel Application Package

    THE COMMONWEALTH OF DOMINICA

    Office of the Maritime Administrator

    APPLICATION FOR STCW’95 CERTIFICATE OF COMPETENCE, DOMINICA MARITIME LICENSE, SEAFARER’S ID AND

    TRAINING RECORD BOOK MAKE SURE ALL BOXES ARE COMPLETED. TYPE OR PRINT CLEARLY. PART I. PERSONAL DESCRIPTION AND INFORMATION:

    1. Last Name (Family Name) First Name (Given Name) Middle Initial 2. Date of Birth 3. Place of Birth (City and Country)

    day month year

    4. Permanent address (street, city and country) 5. Address to which certificate is to be mailed.

    Telephone: Email: Telephone: Email: 6. Name and relationship of person to be notified in emergency. 7. Citizenship 8. Height 9. Weight 10. Color of Hair

     11. Color of eyes 12. Distinguishing Marks 13. Sex Telephone: Email: ; Male ; Female PART II. DESCRIPTION OF HIGHEST GRADE DOMINICA AND FOREIGN CERTIFICATE OF COMPETENCE NOW HELD, IF ANY:

    Grade of Certificate of Competence Certificate # Date Issued Date Expires Country of issue

    a. Dominica Dominica b. Foreign PART III. ELIGIBILITY BASIS ON WHICH APPLICATION IS MADE

    Mark all that apply below, by placing an “X” in the proper box. All applicants are required to have a Dominica SID and TRB if one has not already been issued. A I hereby apply for a Seafarer‟s Identification Document Original Renewal Replacement B I hereby apply for issuance of a Commonwealth of Dominica Certificate of Competence based on recognition of Certificate through

    Endorsement* and Identification Document

    C I hereby apply for issuance of a Commonwealth of Dominica Certificate of Competence based on completion of my approved marine

    education and training program and/or in-service training program* and Identification Document

    *For Parts A , B & C above, please choose grade/level of certificate/identification document desired and any special training applicable:

     II/2 Master > 3000 GT II/2 Chief Mate 500<>3000 VI/1-4 Ordinary Seaman III/3 - Second Engineer between 750

    GT and 3000 kW

     II/2 Master 500<>3000 GT II/3 - Chief Mate < 500 GT III/2 - Chief Engineer 3000 kW or III/1 Officer in Charge of Engineering

    more Watch 750 kW or more

     II/3 Master < 500 GT II/1 Officer in Charge of III/3 - Chief Engineer between 750 III/4 - Engineering Watch Rating

    Navigation Watch > 500 GT and 3000 kW

     II/2 Chief Mate > 3000 GT II/4 - Navigation Watch Rating III/2 - Second Engineer Officer 3000

    kW or more

    Special Qualification/Training

     V/1 Tanker Personnel V/2 Personnel on Ro-Ro V/3 Personnel on Passenger IV/2 GMDSS/ROC ?Oil ? LNG ? LPG Passenger Vessels Vessels other than Ro-Ro

    Note Limitations here:

     Near Coastal Not for Service on Tankers Steam Motor Other _____________________________________

    D I hereby apply for renewal of my Commonwealth of Dominica Certificate of Competence described in Part II (a) or (b), above. E I hereby apply for examination for a Dominica license in the grade of :

    Desired Testing Area: (A telephone number must be listed above to schedule examination)

    F I hereby apply for a Training Record Book for upgrade to capacity: ______________________ Original Renewal Replacement 14. Name of vessel on which now serving (or will join).

CDMP-5000 (Rev. 09.06) -1-

Applicant Name: Date of Birth:

PART IV. SEA SERVICE List and submit proof of at least the minimum service required during the last five years or more to establish eligibility for the Certificate of Competence requested. If you list service aboard Dominica Flag Vessels in an officer capacity, you must describe the Dominica Certificate of Competence held in Part II(a). Propulsion Name of Vessel Deck Officers list Flag Name of Managing Capacity in which served Period of Service Total Service (Steam or Gross Tons/ Operator From To Motor) Engineers list kW years months days month day year month day year Propulsion Power PART V. NAUTICAL, ENGINEERING OR RADIO SCHOOLS ATTENDED. (To be completed by all applicants claiming school attendance to supplement or in lieu of sea service). Dates Attended Type of Degree or Diploma Name of School Address Received upon Graduation From To PART VI. APPLICANTS FOR RADIO OPERATORS CERTIFICATE MUST READ AND SIGN THIS PART VII. APPLICANTS FOR STCW‟95 CERTIFICATE OF COMPETENCE AT THE MANAGEMENT LEVEL MUST SIGN THIS OBLIGATION: AFFIDAVIT/ACKNOWLEDGMENT. By affirming my signature below, I acknowledge that I am obliged to ensure and maintain the secrecy of all These applicants include Master and Chief Mate applicants for the service on board ships of 500 gross tonnage or more, as well as telecommunications of which I may gain knowledge in the course of my services, and that I am likewise obliged Chief Engineer and Second Engineer applicants for service on board ships powered by main propulsion machinery of 750 kW not to reveal the existence or contents of any correspondence to anyone other than the addressee. My propulsion power or more. I hereby understand that I will receive from the Administration a copy of the publication CDP-301, signature further acknowledges that, if I should breach these obligations, my Certificate of Competence issued (“Familiarization with National Maritime Legislation”), which I will acknowledge and affirm I will review to ensure that I become pursuant to this application may be suspended and/or revoked. familiar with the national maritime legislation of the Commonwealth of Dominica relevant to the functions to be performed by me for which I have applied to be certificated. Signature Signature

    Copies of the following identity documents (with name and numbers visible) indicated below are being submitted with this application. Originals are required at time of testing:

    ; Seafarer‟s Book or Card ; Passport ; Commonwealth of Dominica Certificate

    PART VIII. AFFIDAVIT OF APPLICANT APPLICATION CANNOT BE ISSUED UNLESS APPLICANT SIGNS IN BLOCK #21.

    I hereby affirm that all information provided by me in this application and its supporting documents and proofs are true and correct to the best of my knowledge and belief; further, that no certificate issued to me heretofore by any Government has ever been revoked or suspended; or, if revoked or suspended, a full explanation of the circumstances is attached hereto and made part of this

    application.

    20. Date of Application 21. Signature of Applicant

CDMP-5000 (Rev. 09.06) -2-

    PART IX. GENERAL INFORMATION AND INSTRUCTIONS Continued on Pages 4 and 5 of this document.

PART X. IDENTIFICATION INFORMATION

    MARINER APPLICANT FULL NAME : DATE OF BIRTH:

COUNTRY OF CITIZENSHIP: PASSPORT#

    Signature: Please use the space below to sign your name clearly, without touching any of the box lines. This signature will be transferred to your Seafarer‟s ID card.

    Thumbprint: Please use the spaces below for 2 copies each of your left and right thumbprint. Using a traditional blue or black inkpad, roll your thumb from the outer edge over to the right edge in the inkpad and then in the space below, roll from left to right onto the paper to create a clear imprint (repeat the process of inking and transferring for each imprint). We are asking

    for multiple imprints, so we may select the clearest one for imprinting on your Seafarer‟s ID.

    LEFT THUMB RIGHT THUMB

Thumbprint 1 Thumbprint 2 Thumbprint 1 Thumbprint 2

CDMP-5000 (Rev. 09.06) -3-

PART IX GENERAL INFORMATION AND INSTRUCTIONS

    APPLICATION FOR STCW95 CERTIFICATE OF COMPETENCE, DOMINICA MARITIME LICENSE, SID & TRAINING RECORD BOOK

     1. READ INSTRUCTIONS CAREFULLY. Enter all required information. Please use typewriter or print legibly. Failure to properly complete this application or to submit required supporting proofs, etc. will result in rejection of the application or delay its approval. 2. WHERE TO APPLY. Applications must be submitted, by mail or in person, to: Dominica Maritime Registry, Inc. 32 Washington Street, Fairhaven, Massachusetts 02719 USA 3. DOCUMENTS TO BE FILED WITH APPLICATION. The following documents, letter and proofs must be submitted together with this application: (a) Three (3) photographs - facial front view of applicant, passport size, taken within one (1) year preceding application with applicant's signature and name printed on reverse side. Photos may be black and white or color and be 2.0" x 2.0" (50 mm. x 50 mm.) in size. Please do not staple.

    (b) Medical Requirements - All applicants, except as stated below, shall be required to have a physical examination reported on Form CDMP-5000B, Physical

    Examination Report/Certificate, completed by a licensed medical doctor. The original of Form CDMP-5000B must accompany the application. The applicant must

    retain a duplicate copy of Form CDMP-5000B, clearly labeled „certified copy‟ on its face and initialed by the examining physician, as evidence of physical

    qualification while serving on board Commonwealth of Dominica flag vessels. The physical examination must be carried out not more than 12 months prior to date

    of making application. In addition, the following minimum requirements apply: (1) All applicants must have hearing unimpaired for normal sounds. (2) All applicants must have average blood pressure, taking age into consideration. (3) Applicants afflicted with or having medical histories such as follows shall be disqualified for seafarer's identity document: epilepsy, insanity, senility, alcoholism, tuberculosis, acute venereal disease or neuro-syphilis, AIDS, and/or the use of narcotics.

    (c) Applicants holding a Commonwealth of Dominica certificate which has been issued within 12 months prior to the date of application are not required to undergo a

    physical examination. In this regard, they must present their Commonwealth of Dominica certificate and include a copy of the certificate with application for the

    Seafarer's Identification Document (SID) and/or Training Record Book (TRB).

    (d) Identity Document - A copy of a valid passport or other official national identity document, birth certificate, certificate of naturalization, or baptismal certificate or

    parish record recorded within one year of birth along with a valid seaman's document from another maritime nation (if applicable). A copy of these documents

    must be submitted with the application. Applications for renewal must include a copy of the previous document as proof of identity. If the documents presented are

    not in the English language, a certified translation of the documents into English must also be enclosed with the application. These certified translations must

    identify the translator for verification purposes. (e) One letter of recommendation - from applicant's most recent Master or employer if applicant is applying for his or her first Dominica Certificate of Competence. Not required for endorsement or renewal or upgrading of a Dominica Certificate of Competence. (f) Proof of sea service - submit proof of at least the minimum service required to establish eligibility for the license requested. Applicants for Certificate of Competences based on an acceptable national Certificate of Competence must submit at least one (1) year‟s total sea service in the last five (5) years. Applicants for Dominica examination must submit the total sea service as specified in paragraph 8. Proof of sea service can be established by providing a photocopy of the applicant's official "Seafarer's Discharge Book." For service on Dominica ships, a photocopy of the applicant's Dominica Training Record Book, CDP-302, should be provided. (g) Proof of foreign Certificate of Competence - The foreign Certificate of Competence must have a valid “STCW Convention Endorsement” and be issued by a country recognized by the Commonwealth of Dominica. Submit original foreign certificate (which will be promptly returned to the applicant) or a duplicate original of the foreign certificate which is relied upon; or a clear photocopy of the original authenticated by the issuing authority or by a consular officer of the issuing state; or a clear photocopy of the original plus a current certificate of the issuing authority describing the certificate and the holder so as to identify both; or a clear photocopy made by a notary public, commissioner for oaths or other officer authorized by law to administer oaths, verifying that such officer made the photocopy from the original presented to him, and attaching the customary certificate of a public official authenticating the signature of such notary, commissioner or officer. (h) Proof of completion of nautical, marine engineering or radio school training - submit one (1) copy of course completion certificate. (i) All documents not presented in the English Language must have certified English translations attached and enclosed with the application. (j) Renewal of Dominica STCW’95 Certificate of Competence - submit the certificate to be renewed (or certified copy of the certificate), proof of at least one (1) year's sea service within the last five (5) years (or employment ashore directly related to the operation of vessels - e.g. Port Captain, Port Engineer). A Dominica Certificate of Competence which has expired for more than one (1) year cannot be renewed. A completely new set of documents must be filed. (k) Proof of foreign training certificate - radar simulator training, advanced firefighting training, GMDSS certification, first aid training, advanced medical training, survival craft/rescue boat training, and automatic radar plotting aids (ARPA) training - submit one (1) copy of foreign certificate if national Certificate of Competence does not require this training. SEE PARA. 6 FOR TRAINING REQUIREMENTS. 4. SCHEDULE OF FEES. For an equivalent license or examination: Certification Requirement Fee Renewal/Re-Test Issuance of Certificate $150 $150 Seafarer Identification Document $35 $35 Examination Fees for: $175 $125 Master Chief Mate OICNW GMDSS Operator Chief Engineer OICEW MOU Nav/Eng. Officer $150 $125 Ratings: Deck/Eng. & GP-1, GP-2 $75 $75 Special Qualification Certificates (BST, etc.) $35 $35 stTraining Record Book (Deck or Eng.) 1 Issue -0- $175 Training Record Book (Individual Sections) $35 $35 Assessments (does not include travel costs) $500.00 /day n/a Payment must be made by check or money order drawn on a U.S. Bank and payable in U.S. dollars to "Dominica Maritime Registry, Inc." 5. AGE AND CITIZENSHIP REQUIREMENTS. Applicants for Certificate of Competences as Third Mate, Third Assistant Engineer, Radiotelegraph Operator, Radio Telephone Operator and GMDSS Operator must be at least 18 years of age; applicants for all other grades of certificates must be at least 21 years of age. Applicants may be of any nationality and need not be citizens or residents of the Commonwealth of Dominica.

    6. TRAINING REQUIREMENTS (a) Firefighting training - Every candidate for a Master or Mate‟s certificate or an engineer Certificate of Competence for service on vessels of over 3000kW propulsion power must submit proof of completion of an advanced marine firefighting course. (b) Radar simulator training - Every candidate for a Master or Mate‟s certificate must submit proof of completion of a marine radar simulator course.

    CDMP-5000 (Rev. 09.06) -4-

(c)* GMDSS Certification - As of 1 August 1998 every candidate for Third/Second Mate/Mate‟s certificate must hold GMDSS Certification. (d)* First aid training - As of 1 August 1998 every candidate for a Second Mate/Third Mate‟s certificate on vessels over 500 gross tons; every candidate for a Master/Mate‟s certificate on vessels less than 500 gross tons and every candidate for an engineer officer‟s certificate serving on vessels of over 3000kW propulsion power must complete first aid training. (e)* Survival craft/rescue boat training - As of 1 August 1998 every candidate for a Master, Chief Mate, Second Mate, Third Mate or Mate‟s certificate and every candidate for an engineer Certificate of Competence on vessels of over 3000kW propulsion power must complete survival craft/rescue boat training. (f)* Automatic Radar Plotting Aids (ARPA) training - As of 1 August 1998 every candidate for a Master, Chief Mate, Second Mate, Third Mate or Mate‟s certificate must complete automatic radar plotting aids (ARPA) training. * These requirements do not become effective until 1 February 2002 for seafarers who commenced their maritime training and/or sea service prior to 1 August 1998. NOTE: National Certificate of Competences containing the 1995 STCW Endorsement are evidence of completion of the training requirements of (a) through (f) above without having to submit training course certificates. 7. GLOBAL MARITIME DISTRESS AND SAFETY SYSTEM (GMDSS) CERTIFICATES (a) Restricted Operator - Previous service not required. The candidate must pass the written examination for a certificate as GMDSS Restricted operator or present a foreign certificate in equivalent grade. (b) General Operator - Previous service not required. The candidate must pass the written examination for a certificate as GMDSS General Operator or present a foreign certificate in equivalent grade. (c) Second-Class Radio Electronic Operator and Maintainer - Previous service not required. The Candidate must pass the written examination for a certificate as Second-Class Radio Electronic Operator and Maintainer or present a foreign certificate in equivalent grade. (d) First-Class Radio Electronic Operator and Maintainer - Previous service not required. The candidate must pass the written examination for a certificate as First Class Radio Electronic Operator and Maintainer or present a foreign certificate in equivalent grade. 8. SEA SERVICE REQUIREMENTS. Applicants for Dominica examinations must prove the "total" amount of sea service/marine training required for the grade of certificate for which application is made; e.g. an applicant for Second Mate must show three (3) years service for Third Mate and one (1) year service as a certificated Third Mate or five (5) years service in the deck department. For sea service requirements for Dominica examination see REQUIREMENTS FOR MERCHANT MARINE PERSONNEL CERTIFICATION (CDP-300) obtainable upon request to the Office of the Maritime Administrator. Applicants for equivalent Dominica certificates to their national Certificate of Competences must show one (1) year‟s sea service in the last five (5) years. (a) Deck/Navigational Officers - Required service shall have been on board ocean-going vessels of 3000 or more gross tons. At least one (1) year of the total service required shall have been within five (5) years preceding the date of application. (b) Engineer Officers - Required service shall have been on board steam or motor vessels of 3000 or more kW propulsion power. At least one (1) year of the total service required shall have been within five (5) years preceding the date of application. At least six (6) months of the total service required shall at some time have been served in the mode of propulsion applied for. 9. EXAMINATIONS AND TEST CENTERS Information regarding examinations and test centers will be available on our website: www.dominica-registry.com or contact DMRI at 508-992-7170 for further information. 10. EQUIVALENT CERTIFICATES National certificates from the following countries are recognized for the issuance of equivalent Dominica Certificates of Competence under the provisions of STCW95 based on those countries which have been placed on the IMO Report of acceptable countries. As of December 2001, the following countries are listed: Algeria Antigua and Barbuda Argentina Australia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belgium Belize Brazil Brunei Darussalam Bulgaria Canada Cape Verde Chile China Colombia Comoros Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic People's Republic of Korea Denmark Dominica Ecuador Egypt Estonia Ethiopia Fiji Finland France Georgia Germany Ghana Greece Honduras Hungary Iceland India Indonesia Ireland Islamic Republic of Iran Italy Israel Jamaica Japan Jordan Kiribati Kuwait Latvia Lebanon Liberia Lithuania Luxembourg Madagascar Malaysia Maldives Malta Marshall Islands Mauritius Mexico Micronesia (Federated States of) Morocco Mozambique Myanmar Netherlands New Zealand Nigeria Norway Pakistan Panama Papua New Guinea Peru Philippines Poland Portugal Qatar Republic of Korea Romania Russian Federation Saint Vincent and the Grenadines Samoa Saudi Arabia Senegal Singapore Slovak Republic Slovenia Solomon Islands South Africa Spain Sri Lanka Sweden Switzerland Syrian Arab Republic Thailand Tonga Trinidad & Tobago Tunisia Turkey Tuvalu Ukraine United Arab Emirates United Kingdom United Republic of Tanzania United States Uruguay Vanuatu Venezuela Viet Nam Yugoslavia 11. This application is subject to the approval of the Maritime Administrator, Commonwealth of Dominica. In the event approval is not granted, the documents listed in paragraph 3 above together with the fee shall be returned to the applicant at the mailing address indicated. If the application is approved, the SID/TRB will be sent to the mailing address indicated. The „certified copy‟ of Form CDMP-5000B is to be retained by the seafarer as evidence that the application is being processed. 12. Seafarer‟s ID: This identification document conforms to the requirements of the International Labor Organization (ILO) Convention No. 108 (Seafarer's Identity Documents Convention, 1958). It is issued to seafarers of Commonwealth of Dominica flag vessels for use when traveling to or from an assigned vessel or pursuant to instructions from the master of such a vessel. Other uses of the book must be in conformity with Commonwealth of Dominica regulations. ILO 108 does not in any way restrict the right of a member nation from preventing any particular individual from entering or remaining in its territory. Seafarer's Identification Document and Training Record Books are issued under the authority of Chapter 8 of International Maritime Act 2000, as amended. The SID and TRB remains the property of the Maritime Administrator and may be withdrawn at any time. It may not be altered in any way nor be allowed to pass into the possession of an unauthorized person. If the TRB becomes filled with entries, requires alteration, becomes damaged, application for a replacement TRB should be made immediately. If the SID/TRB is stolen, lost, or accidentally destroyed, notification should be given immediately to any office of the Maritime Administrator, and an application for a replacement SID/TRB may be made.

CDMP-5000 (Rev. 09.06) -5-

    COMMONWEALTH OF DOMINICA MARINER CERTIFICATION FEE CALCULATION

DMRI has provided the following fee calculation form for owners to establish a reference of costs that will be

    prescribed for the certification of mariners. Please be advised that mariners will be issued an STCW ’95 certificate, either an original or an endorsement of another administration’s certificate, a Seafarer’s Identification Card and a Training Record Book.

The Fees are as follows:

Application and Issuance of Certificate Fee: USD 150

    Issuance of Seafarer Identification Document: USD 35

    Training Record Book: Free for first Issue

    CDMP-5000 (Rev. 09.06) -6-

    COMMONWEALTH OF DOMINICA

    Office of the Maritime Administrator

    PHYSICAL EXAMINATION REPORT/CERTIFICATE

    LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL

    DATE OF BIRTH PLACE OF BIRTH SEX

    DAY MONTH YEAR CITY COUNTRY ; MALE

    ; FEMALE EXAMINATION FOR DUTY AS: MAILING ADDRESS OF APPLICANT:

    Master ; Mate ; Engineer ; Radio Officer ; Rating ;

    MEDICAL EXAMINATION (See Page 2 for medical requirements) STATE DETAILS ON Page 2

    HEIGHT WEIGHT BLOOD PULSE RESPIRATION GENERAL APPEARANCE

    PRESSURE

    VISION: RIGHT EYE LEFT EYE HEARING: WITHOUT GLASSES / WITH GLASSES / RT. EAR LEFT EAR

    COLOR TEST TYPE: BOOK ; LANTERN ; CHECK IF COLOR TEST IS NORMAL YELLOW RED GREEN BLUE HEAD AND NECK HEART (CARDIOVASCULAR)

    LUNGS SPEECH (DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER) IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION? EXTREMITIES:

    UPPER LOWER

    IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY, OR TO RENDER HIM UNFIT FOR SERVICE AT SEA OR LIKELY TO

    ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD?

Signature of Applicant Date THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN. THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO : ______________________________________________________ Name of Applicant (HE) (SHE) IS FOUND TO BE (FIT) (NOT FIT) FOR DUTY AS A: (MASTER, MATE, ENGINEER, RADIO OFFICER OR RATING)

    NAME AND DEGREE OF PHYSICIAN

ADDRESS

NAME OF PHYSICIAN‟S CERTIFICATING AUTHORITY

DATE OF ISSUE OF PHYSICIAN‟S CERTIFICATE

    SIGNATURE OF PHYSICIAN _____________________________________________ ________________________________

     Date This certificate is issued by authority of the Maritime Administrator and in compliance with the requirements of the Medical Examiner (Seafarers Convention

    1946 (ILO NO. 73))

    CDMP-5000 (Rev. 09.06) -7-

MEDICAL REQUIREMENTS

    All applicants for an STCW‟95 Certificate of Competence, Seafarer‟s Identification Document and a Dominica Training Record Book or certification of special qualification shall be required to have a physical examination reported on this Medical Form completed by a certificated physician. The completed medical form must accompany the application for Certificate of Competence, application for seafarer‟s identity document, or application for certification of special qualifications. This physical examination must

    be carried out not more than 12 months prior to the date of making application for an Certificate of Competence, certification of special qualifications, or a seafarer‟s book. Such proof of examination must reestablish that the applicant is in satisfactory physical condition for the specific duty assignment undertaken and is generally in possession of all body faculties necessary in fulfilling the requirements of the seafaring profession. In addition, the following minimum requirements shall apply:

    1. All applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered voice in the better ear at 15 feet and in the poorer ear at 5

    feet.

    2. Deck officer applicants must have (either with or without corrective lenses) at least 20/20 vision in one eye and at least 20/40 in the other. If the applicant uses

    corrective lenses, he must have vision without corrective lenses of at least 20/160 in both eyes. Deck officer applicants must also have normal color perception

    and be capable of distinguishing the colors red, green, blue and yellow. 3. Engineer and radio officer applicants must have (whether with or without corrective lenses) at least 20/30 vision in one eye and at least 20/50 in the other. If the

    applicant wears glasses, he must have vision without glasses of at least 20/200 in both eyes. Engineer and radio officer applicants must also be able to perceive

    the colors red, yellow and green.

    4. An applicant‟s blood pressure must fall within an average range, taking age into consideration.

    5. Applicants afflicted with any of the following diseases or conditions shall be disqualified: epilepsy, insanity, senility, alcoholism, tuberculosis, acute venereal

    disease or neurosyphilis, AIDS and/or the use of narcotics.

    6. Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired for normal voice communication.

    7. Applicants for able seaman, bosun, GP-1, ordinary seaman and junior ordinary seaman must meet the physical requirements for a deck/navigational officer‟s

    certificate.

    8. Applicants for fireman/watertender, oiler/motorman, pumpman, electrician, wiper, tankerman and survival craft/rescue boat crewman must meet the physical

    requirements for an engineer officer‟s certificate.

     IMPORTANT NOTE: The original copy of the physical report must accompany the application. A duplicate copy clearly labeled

    ‘certified copy’ on its face and initialed by the examining physician must be maintained by the applicant as evidence of physical qualification while serving on board a vessel.

DETAILS OF MEDICAL EXAMINATION

    (To be completed by examining physician)

CDMP-5000 (Rev. 09.06) -8-

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