MDO Form No. 3 Rev.

01/11042000

NOT FOR SALE

Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION

Manila

BOARD OF MARINE DECK OFFICERS CERTICATE OF SERVICE

(All statements herein are subject to verification)

1. TO THE BOARD OF MARINE DECK OFFICER

THIS CERTIFICATE that on board (Name of Vessel) with registry No.: a had actually serve under our supervision , of

(Type of Vessel) (State of Nationality of Vessel) vessel of KW and gross tonnage (Near Coastal/Seagoing) for a period of from to (No. of years) (months) (Days) (Date of Embarkation) (Date of Discharge) as . (Position Held) This certifies further that the above-stated data are all true and that any false statement/s made therein shall be a ground for criminal prosecution. Issued this day of 20 at . SEAL OF VESSEL SEAL OF COMPANY MASTER - Signature Above Printed name Nationality : Kind of License : Registration No. : Date of Registration : Expiry Date :

Name and Signature of Port Captain/Personnel Mgr. Name of Local Ship owner or Managing Agent Address: Telephone Nos. SUBSCRIBE AND SWORN TO before me this . Doc. No. Page No. Book No. Series No. : : : :

day of

,20

,at

NOTARY PUBLIC

Note : This form is good for only one (1) vessel. This form can be reproduced. Any erasure/obliteration may be a ground for denial