International Convention on Standards of Training, Certification

5. The Department of Merchant Shipping may issue, upon request, a Seafarer´sRegistry Certificate. This certificate may be issued to those seafarers who need aconfirmation that they are registered in the Cyprus Registry of Seafarers. Itshould be noted that this certificate is not compulsory. It may be issued uponapplication using form EN05F34 which can be downloaded from the DMSwebsite www.shipping.gov.cy (Training and Certification) and is attachedherewith for easy reference. The fees for the aforementioned certificate are 17.09euro payable in advance.The Department will be at the disposal of Owners, Managers and anyoneconcerned with the matter, for any explanations and clarifications they mayrequire.Serghios S. SerghiouDirectorDepartment of Merchant ShippingccPermanent Secretary, Ministry of Communications and WorksMaritime Offices of the Department of Merchant Shipping abroadInspectors of Cyprus shipsPermanent Secretary, Ministry of Foreign AffairsDiplomatic Missions and Honorary Consular Officers of the Republic of CyprusCyprus Shipping ChamberCyprus Union of ShipownersCyprus Bar Association2

EN05F34/01REPUBLIC OF CYPRUSMINISTRY OFCOMMUNICATIONS AND WORKSDEPARTMENT OFMERCHANT SHIPPINGLEMESOSAPPLICATION FOR THE ISSUE OF A SEAFARER´S REGISTRY CERTIFICATE1. Surname (Family Name) 2. First Name (Given Name)3. Date of birth4. Place of BirthDay:Month:5. Nationality (Citizenship)Year:City:6. SexCountry:MaleFemale7. Surname if diferent on Identity Document8. First Name if diferent on Identity DocumentIdentity DocumentPassportNationalSeaman´s bookIdentity Document Number12. PROOF OF IDENTITYIdentity Document issuing Authority (Country)13. If furnished with Cyprus certificates or endorsement or training documentary evidence orseafarer’s identification and record book, specify Seafarer` s Identification Number14. DECLARATION (THE MAXIMUM PENALTY FOR FALSE DECLARATIONS IS 8543 EURO)I DECLARE THAT THE INFORMATION I HAVE GIVEN IS, TO THE BEST OF MY KNOWLEDGE, TRUE AND COMPLETE. I ALSO DECLARE THAT THEDOCUMENTS SUBMITTED ARE GENUINE.Signature of applicantDate of ApplicationDo not write below this lineFOR OFFICIAL USE ONLYEN05F34/01