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VIP PASSPORT SERVICES, INC.
2012 Louisiana Street
Houston, Texas 77002
713-659-8472 1-800-856-8472 Fax 713-659-3767
W e b s i t e : www.vippassports.com E m a i l : i n f o @ v i p p a s s p o r t s . c o m
WORK ORDER REQUEST FORM
(RETURN THIS FORM WITH EACH REQUEST)
BILLING INFORMATION:
RETURN DOCUMENTS TO:
CONTACT: _____________________________
CONTACT: ______________________
COMPANY: _____________________________
COMPANY: ______________________
ADDRESS: _____________________________
ADDRESS: ______________________
CITY/ST: _____________________________
CITY/ST: ______________________
PHONE:
_____________________________
PHONE:
______________________
CELL:
_____________________________
CELL:
______________________
FAX:
_____________________________
FAX:
______________________
EMAIL:
_____________________________
EMAIL:
______________________
CREDIT CARD INFORMATION:
BILLING INSTRUCTIONS:
CARD#: _______________________________
YOUR P.O. OR REF#:_____________
EXP. DATE: _______
CVV#: ________
SIGNATURE OF CARD HOLDER
REQUIRED: _________________________
AUTHORIZED AMOUNT TO CHARGE MY
CREDIT CARD: US$______________
TRAVELERS NAME: ______________________
DATE OF USA DEPARTURE:
DATE OF BIRTH:
DATE YOU NEED PASSPORT: ________
______________________
________
VIP RESERVATION/FILE LOCATOR NUMBER: ___________
SPECIAL INSTRUCTIONS: ____________________________________________________
__________________________________________________________________________
HOW DID YOU HEAR ABOUT VIP?
REPEAT CUSTOMER__ INTERNET__ REFERRED___ BY_________________ WALK-IN_____
Specializing in Visas, Passports, Document Legalization and Translations
VIP PASSPORT SERVICES, INC.
2012 Louisiana Street
Houston, Texas 77002
713-659-8472 1-800-856-8472 Fax 713-659-3767
W e b s i t e : www.vippassports.com E m a i l : i n f o @ v i p p a s s p o r t s . c o m
PA N AM A SE A M AN ’ S B O O K
MARINE TECHNICIAN
DOCUMENTS REQUIRED:
VALID PASSPORT:
PASSPORT TYPE PHOTO (S):
MEDICAL CERTIFICATE:
COPY OF INVITATION:
OTHER:
1-COPY
6
1
N/A
APPLICATION (S):
ITINERARY/TICKET:
COMPANY LETTER:
RELEASE LETTER:
1
N/A
1
N/A
SEE NEXT PAGES FOR MORE DETAILED INFORMATION. ALSO SEND A
COPY OF YOUR UNDERWATER TRAINING CERTIFICATES (HOET-BOSIET).
PLEASE FORWARD THIS SHEET AND ALL THE ABOVE REQUIREMENTS TO THE ABOVE
LISTED ADDRESS
FEES PER PERSON:
VIP SERVICE FEE: (REGULAR PROCESS)
$75.00
CONSULATE FEE: (SEE NEXT PAGES)
$6.00
MONEY ORDER:
**
□
SPECIAL HANDLING FEE: (NEXT DAY PROCESS)
OTHER FEES:
FEDEX TRANSITORY CETIFICATE
$29.00
*ADD RETURN FEDERAL EXPRESS FEE:
TOTAL:
(NO PERSONAL CHECKS PLEASE)
*FEDERAL EXPRESS FEES:
**VISA PROCESSING TIME
PRIORITY LETTER
$29.00
REGULAR PROCESSSING TIME:
2-DAY LETTER
$23.50
3-DAY LETTER
$19.50
PLEASE MARK THE APPROPRIATE BOX IF YOU NEED
TO HAVE THE VISA ISSUED WITHIN 24 TO 48 HOURS
FROM THE DAY THAT WE SUBMIT YOUR
APPLICATION ($20.00 SPECIAL HANDLING FEE).
SATURDAY LETTER
$41.50
1ST OVERNIGHT DELIVERY
$75.00
COMMENTS:
SEE COMMENTS
THE CONSULATE WILL ISSUE A TRANSITORY CERTIFICATE WITHIN A
COUPLE OF DAYS. YOU CAN EXPECT THE CONSULATE TO TAKE 2 TO 3
MONTHS FOR THE ORIGINAL TO BE RETURNED FROM PANAMA.
REVISED: 10-22-2015 (JENN)
Specializing in Visas, Passports, Document Legalization and Translations
3 x 3 cm.
Foto a color/
Colour photo
REPUBLICA DE PANAMA
REPUBLIC OF PANAMA
AUTORIDAD MARITIMA DE PANAMA
PANAMA MARITIME AUTHORITY
DIRECCION GENERAL DE LA GENTE DE MAR
DIRECTORATE GENERAL OF SEAFARERS
SOLICITUD DE CERTIFICADO DE COMPETENCIA PARA OFICIALES Y
APPLICATION FOR CERTIFICATE OF COMPETENCY FOR
SUBALTERNO DE MARINA MERCANTE
MERCHANT MARINE OFFICERS AND RATINGS
Datos personales de conformidad con el pasaporte – Personal information according to passport
Nombre –Name (first)
Medio –Middle name
No. Pasaporte – Passport No.
Apellido -Surname
Nacionalidad - Nationality
Pais Natal – Country of birth
Ciudad -City
Fecha de Nacimiento-Date of birth
Dia-Day
Mes – month
Ano-Year
Direccion Postal – Mailing Address
Solicitante – Applicant
Empleador – Employer
Caracteristicas del Certificado Solicitado – Detail of Certificate of Competency requested
Funcion – Function
Cargo – Capacity
Nivel – Level
Limitaciones – Limitations Applying (if any)
Limitaciones (si las hubiere) – Limitations Applying (if any)
Si es personal subalterno indique cargo solicitado / If you are a rating indicate position
Endosos a solicitar – If you require the following endorsement(s) please tick the appropiate box
Capitulo V – Chapter V
1.- Regla V/1 Buque tanquero-Regulation V/1 Tanker ship STCW/78/95
APetrolero – Oil Tanker
BQuimiquero – Chemical Tanker
CGasero – Liquefied Gas Tanker
2.- Regla V/2 Buque de pasajeros de transbordo rodado – Regulation V/2 Ro-Ro Passengers ship STCW78/95
3.- Regla V/3 Buque de pasajeros – Regulation V/3 passengers ship STCW 78/95
CURSOS REQUERIDOS POR EL SOLICITANTE EN BASE AL STCW- 78/95/ COURSES REQUIRED ACCORDING TO STCW 78/95
Capitulo VI –Chapter VI
1.-Regla VI/1 familiarizacion, formacion e instrucción basica para la gente de mar en aspectos de seguridad
Regulation VI/1 Familiarization, basic safety training and instruction for all seafarers
2.-Regla VI/2 Suficiencia en el manejo de embarcaciones de Supervivencia, botes de Rescte y botes de Rescate rapidos
Regulation VI/2 Certificates of Proficiency in survival craft rescue boats and fast rescue boats
3.- Regla VI/3 Tecnicas avanzadas de lucha contra incendio –Regulation VI/3 Training in advanced fire fighting
4.-Regla VI/4 Primeros Auxilios y cuidados medicos – Regulation VI/4 Medical first aid and medical care
5.-Curso de Operador S.M.S.S.M. – GMDSS Operator Course
6.-Curso de Radar – Radar Course
7.- Arpa
8.-Otros – Other___________________________________
_______________________________________________
Firma del Aplicante y Fecha-Applicant Signature and date
PARA USO EXCLUSIVO DE LA OFICINA – FOR EXCLUSIVE OFFICE USE
______________________________________________
Firma Oficial de Licencias/ Signature of Duly Authorized Officer
MEDICAL CERTIFICATE FOR PERSONNEL SERVICE ON BOARD
SURNAME:
GIVEN NAME (S):
PLACE OF BIRTH
DATE OF BIRTH:
DAY
MONTH
CITY
YEAR
POSITION ON BOARD:
MASTER
DECK OFFICER
ENGINEERING OFFICER
RADIO OPERATOR
RATING
SEX
COUNTRY
MALE
FEMALE
MAILING ADDRESS OF APPLICANT:
DECLARATION OF THE AUTHORIZED PHYSICIAN
VISION
COLOR TEST TYPE
WITHOUT GLASSES
WITH GLASSES
BOOK
RIGHT EYE
RIGHT EAR
LANTERN
LEFT EYE
YELLOW
RED
GREEN
BLUE
Confirmation that identification documents were checked at the point of examination: YES
Hearing meets the standards in STCW Code, Section A-1/9? YES
Unaided hearing satisfactory? YES
NO
LEFT EAR
NO
NOT APLICABLE
NO
Visual acuity meets standards in STCW Code, Section A-1/9? YES
NO
Colour vision meets standards in STCW Code, Section A-1/9? YES
(the visual test it is required every six years)
NO
Date of the last colour vision test: (Day/Month/Year)
/
/
.
Are glasses or contact lenses necessary to meet the required vision standards? YES
Able for watchkeeping? YES
HEARING
NO
NO
Is applicant taking any non-prescription or prescription medications? YES
NO
Is the seafarer free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to
endanger the health of other persons on board? YES
NO
Hereby I declare that I am in knowledge of the contents of the Physical Examination.
Signature of Applicant
Name of Applicant
Date
CIRCLE APPROPIATE CHOICE: (HE / SHE) IS FOUND TO BE (FIT / NOT FIT) FOR DUTY AS A (MASTER / DECK OFFCIER /
ENGINEERING OFFICER / RADIO OPERATOR / RATING) (WITHOUT ANY / WITH THE FOLLOWING) RESTRICTIONS:
NAME AND DEGREE OF PHYSICIAN:
ADDRESS:
NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY:___________________________________________________________________
DATE OF ISSUE PHYSICIAN’S CERTIFICATE:___________________________________________________________________________
SIGNATURE OF PHYSICIAN:
STAMP OF PHYSICIAN:
EXPIRY DATE OF CERTIFICATE:
This certificate is issued in compliance with the requirements
of the STCW Convention, 1978, as amended and the Maritime Labour Convention, 2006.
DATE: