VIP PASSPORT SERVICES, INC. 2 0 1 2 L o u i s i a n a S t r e e t H o u s t o n , T e xa s 7 7 0 0 2

713-659-8472 1 -800-856-8472 Fax 713-659-3767 W ebs i t e : www.vippassports.com E m a i l : i n f o @ v i p p a s s po r t s . c om

Specializing in Visas, Passports, Document Legalization and Translations

WORK ORDER REQUEST FORM

(RETURN THIS FORM WITH EACH REQUEST) BILLING INFORMATION: RETURN DOCUMENTS TO:

CONTACT: _____________________________ CONTACT: ______________________

COMPANY: _____________________________ COMPANY: ______________________

ADDRESS: _____________________________ ADDRESS: ______________________

CITY/ST: _____________________________ CITY/ST: ______________________

PHONE: _____________________________ PHONE: ______________________

CELL: _____________________________ CELL: ______________________

FAX: _____________________________ FAX: ______________________

EMAIL: _____________________________ EMAIL: ______________________

CREDIT CARD INFORMATION: BILLING INSTRUCTIONS:

CARD#: _______________________________ YOUR P.O. OR REF#:_____________

EXP. DATE: _______ CVV#: ________

SIGNATURE OF CARD HOLDER AUTHORIZED AMOUNT TO CHARGE MY REQUIRED: _________________________ CREDIT CARD: US$______________

TRAVELERS NAME: ______________________ DATE OF USA DEPARTURE: ________

DATE OF BIRTH: ______________________ DATE YOU NEED PASSPORT: ________

VIP RESERVATION/FILE LOCATOR NUMBER: ___________

SPECIAL INSTRUCTIONS: ____________________________________________________ __________________________________________________________________________

HOW DID YOU HEAR ABOUT VIP?

REPEAT CUSTOMER__ INTERNET__ REFERRED___ BY_________________ WALK-IN_____

VIP PASSPORT SERVICES, INC. 2 0 1 2 L o u i s i a n a S t r e e t H o u s t o n , T e xa s 7 7 0 0 2

713-659 -8472 1-800 -856-8472 Fax 713 -659-3767 W ebs i t e : www.vippassports.com Em a i l : i n f o @ v i p p a s s p o r t s . c om

Specializing in Visas, Passports, Document Legalization and Translations

PANAMA SEAMAN’S BOOK M A R I N E T E C H N I C I A N

D O C U ME N T S R E Q U I R E D :

V A L I D P A S S P O R T : 1 - C O P Y A P P L I C A T I O N ( S ) : 1

P A S S P O R T T Y P E P H O T O ( S ) : 6 I T I N E R A R Y / T I C K E T : N / A

M E D I C A L C E R T I F I C A T E : 1 C O M P A N Y L E T T E R : 1

C O P Y O F I N V I T A T I O N : N / A R E L E A S E L E T T E R : N / A

O T H E R : S E E N E X T P A G E S F O R M O R E D E T A I L E D I N F O R M A T I O N . A L S O S E N D A

C O P Y O F Y O U R U N D E R W A T E R T R A I N I N G C E R T I F I C A T E S ( H O E T - B O S I E T ) .

P L E A S E F O R W A R D T H I S S H E E T A N D A L L T H E A B O V E R E Q U I R E M E N T S T O T H E A B O V E

L I S T E D A D D R E S S

FE E S PE R P E R S O N :

V I P S E R V I C E F E E : ( R E G U L A R P R O C E S S ) $ 7 5 . 0 0

C O N S U L A T E F E E : ( S E E N E X T P A G E S )

M O N E Y O R D E R : $ 6 . 0 0

O T H E R F E E S : F E D E X T R A N S I T O R Y / T E M P O R A R Y C E T I F I C A T E

$ 2 9 . 0 0

* A D D R E T U R N F E D E R A L E X P R E S S F E E :

T O T A L : ( N O P E R S O N A L C H E C K S P L E A S E )

* F E D E R A L E X P R E S S F E E S : * * V I S A P R O C E S S I N G T I M E

P R I O R I T Y L E T T E R $ 2 9 . 0 0 R E G U L A R P R O C E S S I N G T I M E : S E E C O M M E N T S

2 - D A Y L E T T E R $ 2 3 . 5 0

3 - D A Y L E T T E R $ 1 9 . 5 0

S A T U R D A Y L E T T E R $ 4 1 . 5 0

1 S T O V E R N I G H T D E L I V E R Y $ 7 5 . 0 0

C O M M E N T S : T H E C O N S U L A T E W I L L I S S U E A T R A N S I T O R Y / T E M P O R A R Y C E R T I F I C A T E

W I T H I N 4 T O 7 D A Y S . Y O U C A N E X P E C T T H E C O N S U L A T E T O T A K E

2 T O 3 M O N T H S F O R T H E O R I G I N A L T O B E R E T U R N E D F R O M P A N A M A .

R E V I S E D : 0 7 - 1 2 - 2 0 1 7 ( S D L )

APPLICATION FOR CERTIFICATES AND ENDORSEMENTS FOR SEAFARERS SOLICITUD DE TÍTULOS Y REFRENDOS PARA LA GENTE DE MAR

TYPE OF APPLICATION - TIPO DE APLICACIÓN

CERTIFICATE - TÍTULO

CERTIFICATE ENDORSEMENT - REFRENDO

COURSE ENDORSEMENT – ENDOSO DE CURSO

DUPLICATE - DUPLICADO

APPLICANT INFORMATION - DATOS DEL SOLICITANTE GIVEN NAME - NOMBRE SURNAME - APELLIDO

PASSPORT Nº - Nº DE PASAPORTE NATIONALITY - NACIONALIDAD

COUNTRY OF BIRTH - PAÍS DE NACIMIENTO DATE OF BIRTH - FECHA DE NACIMIENTO

DAY - DÍA MONTH - MES YEAR - AÑO ADDRESS - DIRECCIÓN PHONE - TELÉFONO

DELIVERY PLACE / CONSULATE - LUGAR DE ENTREGA / CONSULADO

E-MAIL - CORREO ELECTRÓNICO

CAPACITY - GRADO SOLICITADO

ACTUAL OCCUPATION – OCUPACIÓN ACTUAL

NAME OF THE SHIP – NOMBRE DE BUQUE

ENDORSEMENTS REQUESTED - ENDOSOS A SOLICITAR 1. 5.

2. 6.

3. 7.

4. 8.

DETAILS OF BROKER – DATOS DEL TRAMITADOR COMPANY NAME – NOMBRE DE COMPANIA

GIVEN NAME - NOMBRE SURNAME - APELLIDO

PASSPORT Nº - Nº DE PASAPORTE NATIONALITY - NACIONALIDAD

COUNTRY OF BIRTH - PAÍS DE NACIMIENTO DATE OF BIRTH - FECHA DE NACIMIENTO

DAY - DÍA MONTH - MES YEAR - AÑO COMPANY ADDRESS - DIRECCIÓN DE COMPANIA COMPANY PHONE – TELÉFONO DE COMPANIA

COMPANY E-MAIL - CORREO ELECTRÓNICO DE COMPANIA DATE OF APPLICATION- FECHA DE SOLICITUD

DAY - DÍA MONTH - MES YEAR - AÑO

SIGNATURE - FIRMA PHOTO - FOTOGRAFÍA

MEDICAL CERTIFICATE FOR PERSONNEL SERVICE ON BOARD

SURNAME: GIVEN NAME (S):

DATE OF BIRTH: DAY MONTH YEAR

PLACE OF BIRTH CITY COUNTRY

SEX MALE FEMALE

POSITION ON BOARD:

MAILING ADDRESS OF APPLICANT: MASTER DECK OFFICER ENGINEERING OFFICER RADIO OPERATOR RATING DECLARATION OF THE AUTHORIZED PHYSICIAN

VISION COLOR TEST TYPE HEARING

WITHOUT GLASSES WITH GLASSES BOOK

RIGHT EYE LANTERN RIGHT EAR

YELLOW RED LEFT EYE GREEN BLUE LEFT EAR

Confirmation that identification documents were checked at the point of examination: YES NO

Hearing meets the standards in STCW Code, Section A-1/9? YES NO NOT APLICABLE

Unaided hearing satisfactory? YES NO

Visual acuity meets standards in STCW Code, Section A-1/9? YES NO

Colour vision meets standards in STCW Code, Section A-1/9? YES NO (the visual test it is required every six years) Date of the last colour vision test: (Day/Month/Year) / / .

Are glasses or contact lenses necessary to meet the required vision standards? YES NO

Able for watchkeeping? YES NO

Is applicant taking any non-prescription or prescription medications? YES NO

Is the seafarer free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to endanger the health of other persons on board? YES NO

Hereby I declare that I am in knowledge of the contents of the Physical Examination.

Signature of Applicant

Name of Applicant

Date

CIRCLE APPROPIATE CHOICE: (HE / SHE) IS FOUND TO BE (FIT / NOT FIT) FOR DUTY AS A (MASTER / DECK OFFCIER / ENGINEERING OFFICER / RADIO OPERATOR / RATING) (WITHOUT ANY / WITH THE FOLLOWING) RESTRICTIONS:

NAME AND DEGREE OF PHYSICIAN:

ADDRESS:

NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY:___________________________________________________________________

DATE OF ISSUE PHYSICIAN’S CERTIFICATE:___________________________________________________________________________

SIGNATURE OF PHYSICIAN: STAMP OF PHYSICIAN: DATE:

EXPIRY DATE OF CERTIFICATE: This certificate is issued in compliance with the requirements

of the STCW Convention, 1978, as amended and the Maritime Labour Convention, 2006.