ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAPAQARASATAU
1
Embassy of the Republic of the PhilippinesTHIS FORM IS NOT FOR SALE
2
Kuala Lumpur, Malaysia
3
4
 APPLICATION FOR CREW LIST VISA
5
6
7
8
9
10
A. DETAILS OF VESSELTOTAL CREW[ AFFIX VISA HERE ]
11
Vessel Name:
including Master:
12
Official Number (IMO):
13
Flag State / Nationality:
14
Vessel Class/Type:FOREIGN CREW
15
Name of Owner:
16
17
B. DETAILS OF PREVIOUS VOYAGE
18
Please provide the necessary information pertaining to the most recent voyage prior to arrival in the Philippines.
19
Country/Port of DepartureDeparture DateCountry/Port of ArrivalArrival DateName of Local Agent/Handler
20
21
22
23
C. VOYAGE/JOURNEY TO THE PHILIPPINES
24
Please provide the necessary information relative to the voyage of the vessel to the Philippines.
25
Country/Port of DepartureDeparture DatePort of Arrival in the PhilippinesArrival Date (PHL)Name of Local Agent/Handler
26
27
28
G. NOTARIZATION
29
30
31
32
D. DETAILS OF SUCCEEDING VOYAGE
33
34
Please provide the necessary information relative to the next country and port of call from the Philippines.
35
36
37
Port of Departure in the PhilippinesDeparture Date (PHL)Country/Port of ArrivalDate of ArrivalName of Local Agent/Handler
38
39
40
41
42
43
44
45
46
E. ATTESTATION OF AGENTF. DECLARATION OF CAPTAIN/MASTER
47
48
49
 I hereby certify and confirm that the all information supplied I solemnly declare that the information which I have provided
50
51
 in this document and its attachments are true and correct.herein and in the attached crew list is true, accurate and complete
52
53
 I further attest that the signature of the Captain/Master ofto the best of my knowledge, and that I and my crew will abide by
54
55
 the vessel appearing herein is genuine and authentic, and that I amthe laws and regulations of the Republic of the Philippines for the
56
57
 a duly authorized agent acting for and on behalf of the owners of the duration of our stay.
58
59
 vessel.
60
61
62
63
64
65
Signature Above Printed NameSignature Above Printed Name
66
67
(Local Agent)(Captain/Master of Vessel)
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100