South African
Maritime Safety Authority
SEAMAN’S RECORD BOOK NO: ..........................
Merchant Shipping Act, 1951 (Act 57 of 1951)
APPLICATION FOR A SEAMAN’S RECORD BOOK
New Issue Replacement of full book (No.: ................) Replacement of Lost / damaged book
(This application shall be accompanied by testimonials or other suitable proof of previous sea service,
together with two photographs of size 65 mm x 40 mm of the applicant and the prescribed fee).
A.
PARTICULARS OF APPLICANT
Surname First names
(in block letters) (in block letters)
Contact Numbers:
Height Colour of Address
Eyes Hair
Date of Birth Place & Country of Birth
Any scars or tattoos
B.
NAME, RELATIONSHIP AND ADDRESS OF NEXT-OF-KIN OR NEAREST FRIEND
Name
Relationship
Address
C.
TO BE COMPLETED BY APPLICANT
I hereby certify that the particulars appearing in this application are true and correct.
Date: ..........................................................
...............................................
Signature of Applicant
Place: .........................................................
D.
DETAILS OF CERTIFICATES OF COMPETENCY
Grade No. Issuing authority and date
E.
DETAILS OF CERTIFICATE OF SERVICE
Grade No. Issuing authority and date
F.
DETAILS OF TRAINING COURSES
Date of course Particulars of course Certificate obtained
G.
OTHER QUALIFICATIONS
(Certificate of Proficiency in Survival Craft, Certificate as Efficient: Deck Rating, Engine Room Rating and Cook).
................................................................................................................................................................................................
................................................................................................................................................................................................
H.
RECORD OF PREVIOUS SEA SERVICE
Date Description of voyage
Name of Ship or employment (state Rank or Ability Conduct
From To whether foreign-going, rating
coasting, fishing, etc)
I.
Declaration to be made by the applicant before a proper officer or a commissioner of oaths if application is
made at a place where there is no proper officer.
I ....................................................................................................................................................... the undersigned, of
....................................................................................................................................................................... (address)
hereby declare that my seamans record book No. ........................ was issued at the port of ..........................................
The said book is FULL / LOST / DESTROYED / MUTILATED / DAMAGED. The circumstances are the following:
........................................................................................................................................................................................
........................................................................................................................................................................................
......................................................................... .............................................................
DATE SIGNATURE OF APPLICANT
Declared before me at ...................................... on the ...................... day of ....................................................................
.........................................................................
SIGNATURE OF PROPER OFFICER OR
SIGNATURE OF COMMISSIONER OF
OATHS
J.
To be completed by employer or person authorised by employer if application is made at a place
where there is no proper office.
* The ..................................................................................................................................................................................
The application together with the prescribed fee is forwarded herewith for consideration, and I hereby certify that the
particulars appearing on this form are to the best of my knowledge and true and correct, and that the two enclosed
photographs bear a true likeness of the applicant.
Enclosures (testimonials, certificates, etc) ..........................................................................................................................
Address ................................................................................................................................................................................
Date ........................................
.........................................................................
Signature & designation of employer Company
or or person authorised by him
Ships stamp
K.
FOR OFFICIAL USE ONLY
I hereby certify that Record Book No. ............................ has been issued to the applicant whose photograph is affixed.
The fee of .................................... has been brought to account (vide Receipt No. .........................................................
dated .............................................)
Photo of applicant
Place .......................................................
.............................................................
Signature of Clerk
Official Stamp
REQUIREMENTS FOR THE ISSUE OF A
SEAMAN’s RECORD BOOK
Application form to be completed in full and all documents that are
submitted are to be ORIGINALS.
Fee of R380-00
Medical Certificate (Issued by a SAMSA approved Medical
Practitioner)
Familiarisation Course / Pre-Sea Course Certificate
2 x I.D. size photographs
Identity Document or Passport
A letter from your present Employer, certifying that you are
employed on one of their vessels. Quoting the name of the vessel
and the date of employment.
You must be a South African Seaman / Fisherman
or
be employed on a South African Registered vessel.
THIS BOOK IS TO RECORD ALL SEATIME - IT IS NOT A
VISA.
THE SEAMAN’S RECORD BOOK MUST BE COLLECTED
ALONG WITH PROOF OF I D BY THE CANDIDATE
PERSONALLY.
