Maritime Crew Security Clearance Declaration

Personal Details

Full Name

Date of Birth

Nationality

Passport / Seafarer's Number

Vessel & Role Details

Vessel Name

IMO Number

Rank/Role on Vessel

Company / Employer

Security Declarations

1. Have you ever been refused entry or deported from any country? If yes, provide details

2. Have you ever been convicted of any criminal offence? If yes, provide details

3. Do you have any pending criminal charges or investigations? If yes, provide details

4. Have you ever been associated with any group or organisation involved in unlawful activities? If yes, provide details

Declaration & Consent

I hereby declare that the information provided above is true and complete to the best of my knowledge. I consent to the collection, use and disclosure of this information for the purposes of Maritime Crew Security Clearance assessment.

Date

Signature