Employers Statement:

The holder of this document is traveling on behalf of Ship owning company to a ship located at City in order to perform essential services for the construction, refit or commissioning of this ship.

Personal information:

Name	Name and Surname

Nationality	Nationality

Passport number	Passport number

Seaman’s book number	Seaman’s book number

Destination shipyard:

Name	Shipyard’s name

Address	Address

City	City

Contact person	Name and Surname

Telephone number	Telephone number

Details of ship:

Name or yard number	Ship’s name or yard number

Length	in m	Length

Date	Date	Signature