For Official Use

Seamans Book No:

APPLICATION FOR A MALTESE SEAMANS BOOK

.

Merchant Shipping Directorate Malta Transport Centre Marsa MRS1917 Malta Tel: +356 21250360 Fax: +356 21241460 email: applica.stcw@transport.gov.mt

Type or PRINT in ink throughout Please refer to instructions overleaf

1. Particulars of Seafarer
Surname (Family Name) First Name Second Name

Rogers 
William 
Charles
Country of Birth Date of Birth Nationality
England
 
22/09/1992 
British
2. Personal Details
Height in Metres Colour of Eyes Distinguishing Marks (Scars, Tatoos etc.)

1.77 Brown
Passport Number National Insurance Number
111133066 JW 54 07 71D
If you currently hold a Maltese Seamans Book, please state its number

3. Contact Details
Seafarers Address Telephone No.
07875 212 114
Email address
137 Kirkdale, Sydenham, London, SE26 4QJ, England will_spencer_@outlook.com
Address where seamans book is to be forwarded Telephone No.
Showup Srl - Via del Naviganti 10 - 80059 Torre Del Greco +39 0818495702
(Na) Italy Email address
ddenicola@show-up.it
Name of Next of Kin, Relationship to you and their address

Claire Rogers, Mother, 56 Kennedy Drive, Stapleford, Nottingham, NG9 8HW, England, UK
4. Declaration for a Seamans Book
I declare that the information submitted above is true and correct. I am aware that I may be required to provide evidence to support it. I also
declare that I am employed / have been offered employment (select as applicable) on a Maltese registered ship.
Signature: Date:

5. Counter signatory (Seamans Book)

Part 5 is to be filled in by a Member of Parliament, A Justice of the Peace, minister of religion, medical or legal practitioner,
established civil servant, bank official, police officer, head or senior official of a shipping company, union official or any other person
of a similar standing who have known you personally for at least two years. (Members of your family should NOT complete the
declaration).

I certify that the applicant has been known to me for ___ years and that to the best of my knowledge and belief the details given above and
the declaration is correct.
Signature Address or office stamp

Profession Date

6. Kindly fill in all details if paying by credit card

American Express Diners Club Electron Maestro Master Card Visa

Card Number 4 7 6 2 4 8 0 0 6 0 3 7 7 3 6 7 Expiry Date 3 / 18
Card Holders Name Signature

Mr William C Rogers

Form TM/MSD/SCU/015 Issue 1 Transport Malta is the Authority for Transport in Malta set up by ACT XV of 2009 Page 1 of 2
 Requirements for applying for a Maltese Seamans Book

With every application you should send:

a) Two (2) passport size photographs - Photographs are to be taken full face, without a hat/cap and should be printed on normal
photographic paper, unmounted. The photographs should be of clear exposure. Photographs that are too dark or too light will not
be accepted. The counter signatory who countersigns your application in Part 5 should also endorse at least one of the
photographs with the words I CERTIFY THAT THIS IS A TRUE LIKENESS OF ____________ and add his or her signature.

b) The appropriate fee.

c) Any documents of qualification to be entered in your Seamans Book.

d) Satisfactory evidence of your current or intended engagement on a ship registered in Malta. Usually a certificate or statement
from the Master or your employer on an official form or headed paper is sufficient.

e) Proof of Identification (Copy of Passport or Identity Card).

f) In the case of a renewal, please submit your full Seamans Book.

g) In the case of a replacement issue, a declaration explaining the loss or defacement of your Seamans Book. Should the original
Seamans Book be found (if declared lost) it should be immediately returned to this Authority.

h) Part 5 is to be filled in by a Member of Parliament, A Justice of the Peace, minister of religion, medical or legal practitioner,
established civil servant, bank official, police officer, head or senior official of a shipping company, union official or any other
person of a similar standing who has known you personally for at least two years. (Members of your family should NOT complete
the declaration).

i) Any documents of qualification to be entered in your Seamans Book.

j) Satisfactory evidence of your current or intended engagement on a ship registered in Malta. Usually a certificate or statement
from the Master or your employer on an official form or headed paper is sufficient.

k) Proof of Identification (Copy of Passport or Identity Card).

l) In the case of a renewal, please submit your full Seamans Book.

m) In the case of a replacement issue, a declaration explaining the loss or defacement of your Seamans Book. Should the original
Seamans Book be found (if declared lost) it should be immediately returned to this Authority.

n) Part 5 is to be filled in by a Member of Parliament, A Justice of the Peace, minister of religion, medical or legal practitioner,
established civil servant, bank official, police officer, head or senior official of a shipping company, union official or any other
person of a similar standing who have known you personally for at least two years. (Members of your family should NOT complete
the declaration).

Applications are to be sent to:

Transport Malta
Merchant Shipping Directorate
Malta Transport Centre
Marsa MRS1917
Malta

Fax: +356 21241460

email: applica.stcw@transport.gov.mt

Form TM/MSD/SCU/015 Issue 1 Transport Malta is the Authority for Transport in Malta set up by ACT XV of 2009 Page 2 of 2