Application for Accreditation s1

MappsDbase Form Number 1 MARITIME INDUSTRY AUTHORITY 1000 UN Avenue, PPL Bldg. Ermita, Manila APPLICATION FOR ACCREDITATION

I. COMPANY PARTICULARS

Name of Company

Address

TIN Number Tel No. Fax No Organization Corporation Partnership Single Proprietor Cooperative (Pls appropriate box) Nature of Business Other maritime enterprises, (Please Domestic shipping operation Motor banca operation (Pls appropriate box) specify) SEC/DTI/CDA Reg No Date Issued (mm/dd/yyyy)

II. MANAGEMENT COMPETENCE

Name of Principal Officers Position Citizenship Yrs of Shpg Exp

III. VESSEL OWNED/CHARTERED

Name Grt Name Grt 1. 11. 2. 12. 3. 13. 4. 14. 5. 15. 6. 16. 7. 17. 8. 18. 9. 19. 10. 20.

IV. ACCREDITATION DETAILS

Company Representative

Position Type of accreditation MC 9 MC 79 MC 79A Nature of accreditation New Renewal (Pls appropriate box) Operates barge or tanker vessels? Yes No Paid-up capital % Foreign equity

______SIGNATURE OF COMPANY REPRESENTATIVE

------TO BE FILLED UP BY EVALUATORS ------

V. DOCUMENTARY REQUIREMENTS (See reverse side)

Screening Officer Signature Date (mm/dd/yyyy)

Complete Documentary Requirements? Yes No

VI. APPLICATION PROCESSING

Application Control No. Date (mm/dd/yyyy) ATAP # OR Date Amount Paid OR Number (mm/dd/yyyy) Date Evaluator Signature Findings Complied with existing policies (mm/dd/yyyy) Did not comply with existing policies Date Reviewer Signature Recommendation For approval For disapproval (mm/dd/yyyy)