Republic of the marshall islands




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PHOTOGRAPH
Glue 1¾" X 1¾"
(45mm x 45mm) photo in upper left hand corner.
See instructions for
detailed requirements
in paragraph 3(a) of MI-273I.

(STAPLE DOCUMENTATION HERE)

REPUBLIC OF THE MARSHALL ISLANDS

Maritime Administrator

APPLICATION FOR SEAFARER'S IDENTIFICATION AND RECORD BOOK
AND SPECIAL QUALIFICATIONS


1. SURNAME

2. GIVEN NAME(S)

     

     

3. DATE OF BIRTH

4. PLACE OF BIRTH

5. CITIZENSHIP

6. SEX

   /

   /

    

     

     

     

 Male  Female

MONTH DAY YEAR

CITY COUNTRY







7. DISTINGUISHING MARKS (SCARS, BIRTHMARKS, TATTOOS, ETC)

8. APPLICATION IS:

     

 NEW  REPLACEMENT  SPECIAL QUALIFICATION(S) ONLY

     

 RENEWAL

Old Book No.

     

     

 IDENTITY CARD (Optional)

9. PERMANENT ADDRESS (STREET/CITY & COUNTRY)

10. MAILING ADDRESS FOR THIS DOCUMENT

     

     

11. LIST ALL REPUBLIC OF THE MARSHALL ISLANDS (RMI) DOCUMENTS

RMI CERTIFICATE NO.:

     

CAPACITY:

     

SIRB:

     

12. PLEASE INDICATE HERE THE SPECIAL QUALIFICATIONS DESIRED:

     

TOTAL SQCs REQUESTED:

     







13. I HEREBY AFFIRM THAT ALL INFORMATION PROVIDED BY ME IN THIS APPLICATION AND ITS SUPPORTING DOCUMENTS AND PROOFS IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF; FURTHER, THAT NO LICENSE, CERTIFICATE OR DOCUMENT ISSUED TO ME HERETOFORE BY ANY GOVERNMENT HAS EVER BEEN REVOKED OR SUSPENDED, OR, IF REVOKED OR SUSPENDED, A FULL EXPLANATION OF THE CIRCUMSTANCES IS ATTACHED HERETO AND MADE A PART OF THIS APPLICATION.

   

  

    










MONTH

DAY

YEAR













DATE OF APPLICATION

TO BE SIGNED BY APPLICANT IN PRESENCE OF FILING AGENT




AFFIRMED BEFORE ME,




     




REQUIRED DOCUMENTATION




TYPE OR PRINT NAME OF FILING AGENT






















Application (MI-273) completed and signed by applicant.

One (1) 1¾” x 1¾” (45mm x 45mm) photo showing facial front view attached.

Acceptable proof of identification submitted. Copy attached. Certified translation provided if identity document is not in English.

Proof of STCW Basic Training.

Proof of Security Awareness qualifications.

Copy of physical exam submitted.

Letter of commitment for assignment to an RMI flagged vessel (for Seafarer's Identification and Record Book (SIRB) initial applications only).

Requisite fee included.












SIGNATURE OF FILING AGENT

     

FILING AGENT’S TITLE

     





FILING AGENT'S COMPANY







14. SEA SERVICE - List and submit proof of at least the minimum service required to establish eligibility for the special qualification rating requested. (See Part 7.0 of publication MI-118). Proof can be established by a photocopy of the seafarer's own national discharge book or RMI SIRB. If the Officer Certificate of Competence Application by Endorsement (MI-105) is being submitted with this form, the section on sea service may be completed on the MI-105 or a transcript/certified record of sea service may be attached in lieu of completing the section below.

Propulsion (Steam or Motor)

Name of Vessel

IMO Number

Type of Vessel

Deck Officers list Gross Tons / Engineers list kW Propulsion Power

Flag

Capacity in which served

PERIOD OF SERVICE

TOTAL SERVICE

From

To

years

months

days

day

month

year

day

month

year

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

     

     

     

     

     

     

     

  

   

  

  

   

  

  

  

  

15. NAUTICAL, ENGINEERING, OR SPECIALIZED TRAINING COURSES COMPLETED (Where course completion is a pre-requisite for the Special Qualification.)

Name of School/Course

Location of School

Dates Attended

Type of certification
received upon completion

From

To

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

16. GENERAL INSTRUCTIONS

1. Age, experience, educational and medical requirements for “Seafarer Identification and Record Book” and “Special Qualification Certificates” are detailed in "Requirements for Seafarer Certification," publication
MI-118, which is available on board every RMI registered vessel.

2. Please enclose payment with each application: new SIRB=US$60; SQC=$US35 (no fee required for Basic Training, Wiper, Junior Ordinary Seafarer, GP Trainee, General Steward Utility)

3. Payment must be made by check or money order drawn on a bank or branch in the US and payable in US Dollars to "THE TRUST COMPANY OF THE MARSHALL ISLANDS, INC." Fees may also be paid online by credit card.

4. Applications must be sent to:



MARITIME ADMINISTRATOR

c/o MARSHALL ISLANDS MARITIME AND CORPORATE ADMINISTRATORS, INC.

SEAFARERS’ DOCUMENTATION

11495 COMMERCE PARK DRIVE

RESTON, VIRGINIA 20191-1506 USA


or, to any of the Regional Offices named in RMI Marine Notice No. 1-002-1.

5. All applicants for certification of a Special Qualification must hold an RMI Seafarer's Identification and Record Book or apply at the same time for this book. (See Section 5.0 of publication MI-118).



6. Applicants for Special Qualification Certificates holding and/or renewing an RMI Seafarer's Identification and Record Book must submit a copy of Page 2 of that book.

Applicants should keep a photocopy of this completed application as evidence that an RMI Certificate is pending or, for those Filing Agents authorized by the Maritime Administrator to submit orders through the online application system, an Acknowledgement of Application for each SIRB or SQC (MI-273OR) will be generated and, in lieu of the copy of the application, the MI-273OR shall be retained by the seafarer as evidence that the application is being processed. The application or MI-273OR shall be valid for up to 90 days as proof of authorization to serve on an RMI flagged vessel in the capacity for which the seafarer has applied.




Page 1 of 2 MI-273 (Rev. 5/15)


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