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0 - Coc Eligibility Form

This document is an Examination Eligibility/Assessment Form for the Nigerian Maritime Administration and Safety Agency, intended for applicants seeking to sit for Certificate of Competency examinations for deck and engineer officers. It requires personal details, educational background, qualifying sea service, and necessary document submissions, along with a declaration from both the applicant and a referee. Additionally, it outlines the payment process and submission deadlines for the examination application.

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dobi5166
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33 views4 pages

0 - Coc Eligibility Form

This document is an Examination Eligibility/Assessment Form for the Nigerian Maritime Administration and Safety Agency, intended for applicants seeking to sit for Certificate of Competency examinations for deck and engineer officers. It requires personal details, educational background, qualifying sea service, and necessary document submissions, along with a declaration from both the applicant and a referee. Additionally, it outlines the payment process and submission deadlines for the examination application.

Uploaded by

dobi5166
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

NIMASA-MSSSD-E&C-EEA-02

EXAMINATION ELIGIBILITY/ASSESSMENT FORM


PASSPORT SIZE

HEIGHT- 4.2CM

WIDTH – 3.5CM

NIGERIAN MARITIME ADMINISTRATION AND SAFETY AGENCY


APPLICATION FOR ASSESSMENT FOR ELIGIBILITY TO SIT CERTIFICATE OF COMPETENCY
(STCW’78, AS AMENDED) EXAMINATIONS: DECK / ENGINEER OFFICERS.

IMPORTANT please complete this form in BLOCK LETTERS and in BLACK INK. If a
section is not relevant to your application, please enter NIL.
Enclose photocopies of all documents necessary to establish your eligibility
for the examination.
The back of one of the passport photographs must include your name in BLOCK
LETTERS and the signature of your referee with the declaration “I certify
that this is a true likeness of Mr./Miss/etc.”

1. PERSONAL DETAILS
SURNAME: FORENAMES:
DAY MONTH YEAR
DATE OF BIRTH:
0 3 1 2 1 9 9 0 PLACE OF BIRTH: Warri
NATIONALITY: Nigerian DISCHARGE BOOK NO:NO61936
RESIDENTIAL ADDRESS: No 3 Newton close Ekpan
CITY: Warri
TEL: 09034177841
E-MAIL ADDRESS: Feke5166@gmail.com

EDUCATIONAL BACKGROUND
SCHOOL(S)/COLLEGE(S) ATTENDED FROM TO QUALIFICATION
South Shields Marine School UK 12/2013 06/2016 HND
Liverpool John Moores University 01/2017 11/2017 BSC

Page 1 of 4
NIMASA-MSSSD-E&C-EEA-02
2. CERTIFICATE APPLIED FOR:
CAPACITY POWER LIMITS (KW) TONNAGE LIMITS (GRT) AREA LIMITATION
(ENGINEERS) (DECK OFFICERS) N.C.V/ UNLIMITED

LNG Carrier 115993 UNLIMITED

2A. PREVIOUS CERTIFICATE HELD:


CAPACITY POWER LIMITS (KW) TONNAGE LIMITS (GRT) AREA LIMITATION
(ENGINEERS) (DECK OFFICERS) N.C.V/ UNLIMITED

3 QUALIFYING SEA SERVICE (FROM DATE OF LAST COC IF ANY) ALL RELEVANT SEAGOING
SERVICE MUST BE LISTED. Sea service on foreign ships will be accepted Subject
to verification.

LENGTH OF VOYAGE: this must be given in calendar months and days, e.g. from
13 Jan to 15 Feb 1 month and 3 days. Odd days should be added together and
reckoned at 30 days to the month. Deck applicants to enter in the column for
Tonnage/Power: GROSS TONNAGE while the Engineering candidates should indicate
KW power.(Start from the current sea term)

SHIP AND VOYAGE DETAILS


Name of Port of IMO/ Tonnage Rank Dates Duration
Vessel Registry Official / Power FROM TO MTH DAYS
No.
LNG SOKOTO Bonny 9216303 114354mt D/C 26/5/21
28/11/21 6 5
LNG River Niger Bonny 9262235 115993mt D/C 18/01/22 5/7/22 5 21
LPG Alfred Temile Bonny 9859882 17980mt D/C 6/1/23 13/1/23 0 8

Page 2 of 4
NIMASA-MSSSD-E&C-EEA-02
Before a certificate a Competency can be issued to you, the originals
of the following documents must be sighted. However submit only
photocopies with this application .
4A. ALL APPLICANTS Date of issue tick box if For official
enclose use only
Discharge Book
Sea Service Testimonials
Two passports Size color photograph
Valid Medical Fitness Certificate
Basic Mandatory Certificates
Advanced Fire Fighting Certificate
Proficiency in Survival Crafts
Proficiency in medical First Aid
Certificate of Competency (if any)
High Voltage
Engine Room Resource Management
Ship Security Officer
HELM
4B. DECK APPLICANTS
GMDSS (GOC)
MEDICAL CARE
NARAS (Operational)
NARAS (Management)
Bridge Resource Management
ECDIS

5. SIGNATURE AND DECLARATION BY APPLICANT


I declare that the information contained in this application are to the best
of my knowledge, true and complete. I also declare that the documents
submitted along with this form are genuine, and signed by the person(s) who
are authorized to do so.
Signature of Applicant: …………………………………………………………………………Date……………………………………………… 18/12/2024
6. PARTICULARS OF REFEREE, SIGNATURE AND DECLARATION
NAME: Okon Gideon
ADDRESS: Ikot Ibibo street
TOWN: Uyo STATE: Akwa Ibom
OCCUPATION: Seafarer
PHONE NO: 0808 848 8923 E-mail: gideonokon25@yahoo.com
(The referee should be a medical doctor, senior civil servant, legal practitioner or someone of similar standing
who is not related to you.)
I declare that the information given by the applicant are to the best of my knowledge, true and
complete, and that the photographs submitted bear true likeness of the applicant.
18/12/2024
Referee’s Signature:……………………………………………………………… Date……………………………………
7. PAYMENT
Page 3 of 4
NIMASA-MSSSD-E&C-EEA-02
The appropriate, Examination fee is payable on application to sit a specific
examination upon the receipt of your Notice of Eligibility. Payment MUST be
made to NIMASA account at the designated banks, not later than 21 days
before the date of examination AND duplicate of evidence of payment returned
to the office of the Director, MSSSD

NOTE: Completed examination forms with evidence of payment of Examination


fees MUST be returned to;

THE DIRECTOR
MARITIME SAFETY AND SEAFARERS STANDARD DEPARTMENT. (MSSSD)
NIGERIA MARITIME RESOURCE DEVELOPMENT CENTRE
KIRIKIRI, APAPA. LAGOS. NIGERIA.
Tel: 09076361503

To reach him NOT later than Two weeks before the date of examination.

8. OFFICIAL USE ONLY


Medical standards met Yes No
Qualifying seagoing services met Yes No
Ancillary certificate supplied Yes No
Approved for issue of Notice of Yes No
Eligibility

Reason(s) for rejection of application

Name of Assessor:………………………………………………………………………………………………………………………………
Designation:……………………………………………………………………………………………………………………………………………
Signature:……………………………………………………………………………………………………………………………………………………

Page 4 of 4

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