<p> PANAMA MARITIME AUTHORITY Technical Office – Segumar Panama Pan-Canal Building 4th fl., Omar Torrijos Herrera Ave. Albrook Panama City, Panama Tel: (507) 501-5361/62/50 Fax: (507) 501-5363/64 E-mail: [email protected] APPLICATION FOR MOBILE OFFSHORE DRILLING UNIT (MODU) MINIMUN SAFE MANNING CERTIFICATE ………………………………………………………………………………………………………………………...... Name of </p><p>Applicant: Address: </p><p>Phone: Fax: Email: ………………………………………………………………………………………………………………………….. GENERAL INFORMATION Name of Registration Call Letter: MODU: No. IMO No.: Year of built: Existing Unit New Unit ITC 69 Gross Net Vessel classified with GMDSS Tonnage: Tonnage: YES NO Non-Self Propelled IF Self Propelled Main Engine’s Power (HP or Kw): </p><p>Has there been a MSM for this MODU? NO IF YES MSMC No.: Previous ITC: ………………………………………………………………………………………………………………………….. TYPE OF MODU Surface Units Bottom-Supported Drilling Rigs 1. Semi-Submersible or Colum stabilized 1. Submersible unit 2. Drill ships 2. Self-Elevating (Jack-Up) ……………………………………………………………………………………………… OPERATION MODES ON LOCATION TRANSIT CONDITION (underway) (check one of the following) (check one of the following) Floating Moored with anchors Underway 16 Hrs. or less in any 24 Hrs. periods Dynamically positioned Underway 17 to 72 Hrs. Underway 72 Hrs. or less Bottom Bearing Underway more than 72 Hrs. Moveable legs Under Tow Others ...... PRESENT MANNING ON BOARD ( ) Offshore Installation Manager ( ) Master ( ) Chief Engineer ( ) Barge Supervisor ( ) Chief Officer ( ) First Engineer ( ) Ballast Control Operator ( ) Deck Officer ( ) Engineer Officer ( ) A.B. Seaman ( ) A.B. Seaman ( ) Oiler(s) / Motormen ( ) O. Seaman ( ) O. Seaman ( ) Certificated Person ( ) Certificated Person ( ) Certificated Person ( ) Radio Officer Enclosed you will find check for amount of U.S. $ 150.00 Payable to “PANAMA MARITIME AUTHORITY”</p><p>SEG-01-09-03 Pag. 1 / 1 Rev. Nov. 2012</p>