Proforma (3 Sheets) for Dispensation (Age/Rank) on Engineering side

(1st two pages may be initialled, last page to be signed in full by the applicant)

(a) Particulars of Ship:

1 2 3 4 5 6 7 8 Name of Ship Type of Ship Gross Tonnage Port of Registry / Off. No.
Main Propulsion Power (KW)

Trading Area of Ship Date from which dispensation is required Any other information

(b) Particulars of the Seafarer/Rank for whom/which dispensation is sought:

1 2 3 4 5 6 7 1 2 3 4 5 6 Full Name Date of Birth / Age Yrs. Nationality Grade of CoC & Validity CoC No., Verification status Rank Any other information Name of Company Reference of request letter (Letter no./ dated) Type of Dispensation requested for (strike out as inapplicable) Period for which Dispensation is requested Grade for which Dispensation is requested Justification for dispensation request with documentary evidences as applicable (w.r.t. Annexure1) Processing fee paid Any other information

(c) Details of Dispensation sought:

Dispensation from Safe Manning / Age Dispensation / Permission to sail one rank lower to the Grade of CoC

7 8

YES / NO

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(e) Plying details (for period during which dispensation is sought):

1 2 3 4 5 6 Voyage duration(s), as applicable, in no. of days Sea-area of plying Prevailing weather condition Port visits (from & to) Duration of Port stay(s), in days Any other information, which will add clarity to the dispensation request.

(f) Detention details (if applicable):

1 2 Whether vessel has been detained in the previous six months. If Yes, list the major deficiencies, which led to detention. Yes/No

Any other information, (relating to detention, including under Clause 17)

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