MDO Form No.

3 NOT FOR SALE

Rev. 01/11042000

Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION
Manila

BOARD OF MARINE ENGINE OFFICERS

CERTICATE OF SERVICE
(All statements herein are subject to verification)

1. TO THE BOARD OF MARINE ENGINE OFFICER

THIS CERTIFICATE that had actually serve under our supervision
on board , of
(Name of Vessel) (Type of Vessel) (State of Nationality of Vessel)
with registry No.: a vessel of KW and gross tonnage
(Near Coastal/Seagoing)
for a period of from to
(No. of years) (months) (Days) (Date of Embarkation) (Date of Discharge)
as .
(Position Held)

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 20 at .

SEAL OF VESSEL
SEAL OF COMPANY

MASTER - Signature Above Printed name

Nationality :
Name and Signature of Port Captain/Personnel Mgr. Kind of License :
Registration No. :
Date of Registration :
Name of Local Ship owner or Managing Agent Expiry Date :
Address:

Telephone Nos.

SUBSCRIBE AND SWORN TO before me this day of ,20 ,at

.

Doc. No. :
Page No. :
Book No. :
Series No. : NOTARY PUBLIC

Note : This form is good for only one (1) vessel. This form can be reproduced. Any erasure/obliteration may be a
ground for denial