Please note that you must also apply for a Revalidation if your lost
MSF 4299 REV 11/17
APPLICATION FOR THE REPLACEMENT OF A CERTIFICATE OF COMPETENCY OR CERTIFICATE OF EQUIVALENT COMPETENCY (including ECDIS and High Voltage limitation removal)
RC
Please note that you must also apply for a Revalidation if your lost Certificate of Competency (CoC) or Certificate of Equivalent Competency (CEC) has expired. If this is the case please also complete form MSF4201 or MSF4203 (respectively). This form can be used for ECDIS and High Voltage limitation removal. We do not offer a counter service. 1 PERSONAL DETAILS Sex Male / Female
Surname / Family name
Name
Title Mr/Mrs/Miss/Capt etc
Forename(s) in full Date of Birth Place of Birth
Country of Birth
Nationality
Discharge Book No Full Home Address
Address for return of documents (if different from home address)
Address
DOB
District Town / City County/State Post Code/Zip Country Telephone No
Mobile No.
Email Address
Dated Name and Address of Police Station
Please do not write below this line Received:
SDS No
Fee:
Receipt No RMS No COC No
1
SDS
All losses of CoCs or CECs MUST be reported to the Police (including theft, loss or destruction). Attach a copy of the Police report to this application. Please include a translation if not in English. If you cannot obtain a Police report please email the MCA before applying. Not applicable for ECDIS/HV limitation removal. Police Report Reference Number
RC Please complete either section 2 (ECDIS/HV removal) or section 3 (replacement CoC) 2 ECDIS and High Voltage (HV) Limitation Removal Please (✓ )
Official use only
Original Certificate of Competency Original MCA approved ECDIS or High Voltage Certificate Fee £58 (UK), £68 EU or EEA or £78 for the rest of world For a list or MCA approved and MCA accepted ECDIS or High Voltage course certificates please visit our website www.gov.uk and search “MCA ATP”.
3 Lost, Stolen or Damaged CoC Type of lost Certificate (Certificate of Competency or Certificate of Equivalent Competency):
Certificate No:
Grade of certificate:
Have you lost a COC or CEC before
Yes
No
Date of issue (please approximate if unknown):
2 passport size photographs
Please provide FULL details of the circumstances of the loss of your certificate, including date, place, time and contact details of any witnesses. We may need to contact witnesses or contact you again for further information.
2 If there is insufficient space, please continue on a separate sheet.
RC
4 Your signature and declaration
(The maximum penalty for a false declaration is £5000)
I understand that completing and returning this form will result in the related Certificate being cancelled, that it may never be used again and, if subsequently found, it should be returned to the Maritime and Coastguard Agency (MCA) immediately. The information given on this form is true to the best of my knowledge, true and complete. for office use only
Date ………………………
IMPORTANT – IMPORTANT PLEASE KEEP WITHIN BORDER
5 Where to send your application Completed applications should be sent to the following address: Maritime & Coastguard Agency Seafarer Training & Certification Branch Spring Place 105 Commercial Road Southampton SO15 1EG Tel: +44(0)203 8172000; Fax +44(0) 2380 329252
Email: [email protected] or [email protected] or [email protected] Website: www.gov.uk/mca In your own interest use Recorded Delivery if posting within the UK and Registered Post from abroad. Your documents will be returned by courier. The MCA cannot accept any responsibility for documents lost in the post.
3
RC
6 PAYMENT Please enclose the appropriate fee (as laid down in the current Merchant Shipping Fees Regulations). Payment should be made in £ sterling by cheque, postal order or banker’s draft, credit or debit card. Cheques, Postal Orders and Bankers Drafts should be made payable to the “Maritime and Coastguard Agency” and crossed “Account Payee” and “not negotiable”. Cheques and drafts should be drawn at a UK bank. CASH WILL NOT BE ACCEPTED. World-wide postage is included in the fee. I enclose the MCA fee of £…58.00* (UK), £68* EU/EEA or £78* (rest of world)… * Delete as appropriate Please tick (✓ ) the appropriate box below to indicate your chosen method of payment. Maestro
Visa
MasterCard
Cheque/bankers draft
Postal Orders
Please charge my Maestro/Visa /MasterCard/Access/Delta Card: £… Name of Card Holder Card Number (16-18 digits) Start Date Expiry Date Maestro Issue Number (Maestro Cards only)
Security Code
The Security Code is the last three digits of the numbers on the reverse of the card, near to the signature strip. (See example right)
Signature…………………………………………………… Date……………………………… For official use only: Name, if different from card holder: SDS number: Email, if not stated above: All payment details entered on SDS (initial):
6 PRIVACY STATEMENT Personal information which you supply to us will be used to process your application to meet the applicable Standards of Training Certification and Watchkeeping (STCW) requirements. To check and report on how effective the MCA and the services it commissions have been. To make sure that the MCA gives value for money. We may use your information to investigate complaints, legal claims or important incidents. We may use your information for crime prevention and prosecution of offenders. The information you provide is primarily used for issuing your UK Certificate of Competency (CoC)/Certificate of Equivalent Competency (CEC) but may also be used for other related purposes, and shared with other statutory bodies/organisations to enable them to fulfil their statutory obligations. We will not disclose any financial details you provide to us. Once your payment has been processed all financial details are securely destroyed. For more information on how we use your information, and your rights to access information we hold on you, please see our full privacy policy available on our website: https://www.gov.uk/government/organisations/maritime-and-coastguard-agency
4
APPLICATION FOR THE REPLACEMENT OF A CERTIFICATE OF COMPETENCY OR CERTIFICATE OF EQUIVALENT COMPETENCY (including ECDIS and High Voltage limitation removal)
RC
Please note that you must also apply for a Revalidation if your lost Certificate of Competency (CoC) or Certificate of Equivalent Competency (CEC) has expired. If this is the case please also complete form MSF4201 or MSF4203 (respectively). This form can be used for ECDIS and High Voltage limitation removal. We do not offer a counter service. 1 PERSONAL DETAILS Sex Male / Female
Surname / Family name
Name
Title Mr/Mrs/Miss/Capt etc
Forename(s) in full Date of Birth Place of Birth
Country of Birth
Nationality
Discharge Book No Full Home Address
Address for return of documents (if different from home address)
Address
DOB
District Town / City County/State Post Code/Zip Country Telephone No
Mobile No.
Email Address
Dated Name and Address of Police Station
Please do not write below this line Received:
SDS No
Fee:
Receipt No RMS No COC No
1
SDS
All losses of CoCs or CECs MUST be reported to the Police (including theft, loss or destruction). Attach a copy of the Police report to this application. Please include a translation if not in English. If you cannot obtain a Police report please email the MCA before applying. Not applicable for ECDIS/HV limitation removal. Police Report Reference Number
RC Please complete either section 2 (ECDIS/HV removal) or section 3 (replacement CoC) 2 ECDIS and High Voltage (HV) Limitation Removal Please (✓ )
Official use only
Original Certificate of Competency Original MCA approved ECDIS or High Voltage Certificate Fee £58 (UK), £68 EU or EEA or £78 for the rest of world For a list or MCA approved and MCA accepted ECDIS or High Voltage course certificates please visit our website www.gov.uk and search “MCA ATP”.
3 Lost, Stolen or Damaged CoC Type of lost Certificate (Certificate of Competency or Certificate of Equivalent Competency):
Certificate No:
Grade of certificate:
Have you lost a COC or CEC before
Yes
No
Date of issue (please approximate if unknown):
2 passport size photographs
Please provide FULL details of the circumstances of the loss of your certificate, including date, place, time and contact details of any witnesses. We may need to contact witnesses or contact you again for further information.
2 If there is insufficient space, please continue on a separate sheet.
RC
4 Your signature and declaration
(The maximum penalty for a false declaration is £5000)
I understand that completing and returning this form will result in the related Certificate being cancelled, that it may never be used again and, if subsequently found, it should be returned to the Maritime and Coastguard Agency (MCA) immediately. The information given on this form is true to the best of my knowledge, true and complete. for office use only
Date ………………………
IMPORTANT – IMPORTANT PLEASE KEEP WITHIN BORDER
5 Where to send your application Completed applications should be sent to the following address: Maritime & Coastguard Agency Seafarer Training & Certification Branch Spring Place 105 Commercial Road Southampton SO15 1EG Tel: +44(0)203 8172000; Fax +44(0) 2380 329252
Email: [email protected] or [email protected] or [email protected] Website: www.gov.uk/mca In your own interest use Recorded Delivery if posting within the UK and Registered Post from abroad. Your documents will be returned by courier. The MCA cannot accept any responsibility for documents lost in the post.
3
RC
6 PAYMENT Please enclose the appropriate fee (as laid down in the current Merchant Shipping Fees Regulations). Payment should be made in £ sterling by cheque, postal order or banker’s draft, credit or debit card. Cheques, Postal Orders and Bankers Drafts should be made payable to the “Maritime and Coastguard Agency” and crossed “Account Payee” and “not negotiable”. Cheques and drafts should be drawn at a UK bank. CASH WILL NOT BE ACCEPTED. World-wide postage is included in the fee. I enclose the MCA fee of £…58.00* (UK), £68* EU/EEA or £78* (rest of world)… * Delete as appropriate Please tick (✓ ) the appropriate box below to indicate your chosen method of payment. Maestro
Visa
MasterCard
Cheque/bankers draft
Postal Orders
Please charge my Maestro/Visa /MasterCard/Access/Delta Card: £… Name of Card Holder Card Number (16-18 digits) Start Date Expiry Date Maestro Issue Number (Maestro Cards only)
Security Code
The Security Code is the last three digits of the numbers on the reverse of the card, near to the signature strip. (See example right)
Signature…………………………………………………… Date……………………………… For official use only: Name, if different from card holder: SDS number: Email, if not stated above: All payment details entered on SDS (initial):
6 PRIVACY STATEMENT Personal information which you supply to us will be used to process your application to meet the applicable Standards of Training Certification and Watchkeeping (STCW) requirements. To check and report on how effective the MCA and the services it commissions have been. To make sure that the MCA gives value for money. We may use your information to investigate complaints, legal claims or important incidents. We may use your information for crime prevention and prosecution of offenders. The information you provide is primarily used for issuing your UK Certificate of Competency (CoC)/Certificate of Equivalent Competency (CEC) but may also be used for other related purposes, and shared with other statutory bodies/organisations to enable them to fulfil their statutory obligations. We will not disclose any financial details you provide to us. Once your payment has been processed all financial details are securely destroyed. For more information on how we use your information, and your rights to access information we hold on you, please see our full privacy policy available on our website: https://www.gov.uk/government/organisations/maritime-and-coastguard-agency
4
