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01/11-04-2000
7431698
gross tonnage
to (Date of Embarkation)
(Date of Discharge)
This certifies further that the above-stated data are all true and that any false statement/s made therein shall be a ground for criminal prosecution.
Issued this day of at ________ ________
.
SEAL OF VESSEL SEAL OF COMPANY CAPT. Dexter R. Velasquez Master - Signature Above Printed Name Nationality : FILIINO Kind of License : MASTER MARINER Registration No. : __________ Date of Registration : 20 June 2011_____ Expiry Date : 20 June 2016_____
Name of Local Shipowner or Manning Agent Address: 3rFloor Shipping Center Bldg.,
707 A. Soriano Jr. Ave., Intramuros, Manila Telephone Nos. 527-70-13/ 527-70-09
SUBSCRIBED AND SWORN TO before me this at Doc. No. Page No. Book No. Series of Note: : : : : .
day of
,20
This form is good only for one (1) vessel. erasure/ obliteration may be a ground for denial.