Application form for recognition of non-new Zealand seafarer certificates

Transcription

1 Application form for recognition of non-new Zealand seafarer certificates Last updated: April 2014 About this form Use this form to apply to have a foreign (non-new Zealand) seafarer certificate recognised. You must complete this form correctly for your application to be valid. For information about the documents you need to provide with your application, refer to the guidelines for recognition on Maritime New Zealand s website: To complete this form you will need four passport-sized photos or an electronic copy certified copies of the certificate(s) you wish to have recognised. Charges and payment There is a charge for having a foreign certificate recognised. Information about the application fee and how to pay is available on Maritime New Zealand s website. maritimenz.govt.nz/howtopay Send your completed form to: Maritime New Zealand PO Box Wellington, 6146 New Zealand Page 1 of 5

2 1. Personal details Complete all of this information. Surname First name(s) Nationality Place of birth Give the city and country Date of birth Passport number and issuing country Home phone Mobile phone address Eg Eg Postal address City and country Postcode Residential address (if different from postal address) City and country Page 2 of 5

3 2. Purpose of recognition Please indicate what your application is for: Foreign STCW certificate/endorsement Other foreign certificate/endorsement (including STCW-F certificates) Note: If you are applying for recognition of an Australian certificate, refer to the information about Australian certificates on Maritime New Zealand s website: maritimenz.govt.nz/seafarers Please indicate how you intend to use the recognition: To work in a capacity requiring an STCW certificate To work on a New Zealand-flagged fishing vessel Other If you have ticked this box, please specify below (for example, size and type of vessel, operating limit, capacity, etc). Page 3 of 5

4 3. Your certificates List the certificate(s) you want to have recognised. no. Issue date Issuing authority (including country name) Capacity and limitations applying (if any) Endorsements (if any) Ancillary certificate(s) held no. Issue date Issuing authority (including country name) Capacity and limitations applying (if any) Endorsements (if any) Ancillary certificate(s) held Page 4 of 5

5 4. Declaration By ticking this box, you (the above named person): declare that the particulars entered in this application form are true and correct and that the papers sent with this form are true and genuine documents given and signed by the persons whose names appear on them; and authorise Maritime New Zealand to: 1. use any of the foregoing personal information provided for the purpose relating to maritime safety, or to further the lawful activities of Maritime New Zealand; and 2. disclose the information to any division of Maritime New Zealand or its agents, or its contractors, or to any other person where such disclosure is necessary to further the purposes, activities or objectives specified in (1) above. Caution: Providing false information relating to the grant of a maritime document is an offence under section 406 of the Maritime Transport Act 1994 and is subject, in the case of an individual, to imprisonment for a term not exceeding 12 months or a fine not exceeding NZD$10,000. Your signature Date 5. Photo requirements You must sign inside the two boxes below and attach four passport-sized photos of yourself (inside a sealed envelope) to the top of this page, or send an electronic copy. We need four photos for each certificate you are applying for. Remember to include extra photos if you are applying for more than one certificate. Sign here Sign here Please make sure your signature fits into the box. Page 5 of 5