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.
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