APPLICATION FOR SKIPPER LICENCE
App. No:
(office use)
SECTION A General
1
Surname:
2
Name:
3
Nationality:
4
National Identity Card Number (for over 18 years)
5
Home address:
6
Telephone no::
7
Sex:
8
Height:
SECTION B
Next of kin (any change MUST be notified as soon as possible)
a
Name:
b
Relationship:
c
Address:
d
Phone number:
SECTION C
Application for :
Skipper licence for private use
Skipper licence for commercial use
Type of examination preferred
Written in English
Oral in Creole
Written in French Language
Practical Only (for those who have already passed oral or written examination)
Exemption
Licence. No:
(office use)
SECTION D
other qualification (if any)
If applicant is holder of any skipper's licence / qualifications please indicate full particulars (attach copies)
SECTION D
(
Tick where applicable)
Have you ever taken part in this skipper's competency test before?
YES
NO
SECTION F (
Tick where applicable)
Do you suffer from any disease or physical disability that could distort your ability to operate a pleasure Craft?
YES
NO
SECTION G Note: this application form must be submitted with the following documents.
Copy of applicant's National Identity Card
Copy of Skiper's license (if any)
Two recent identical passport size photographs (and signed at the back)
Medical Certificate dully filled in. (valid for a period of 3 years) where applicant is of the age of 60 or more.
Note: Certificate of Medical Fitness Template available on demand.
SECTION H
non-residents
(in addition to
SECTION
G/where applicable)
Copy of passport with date of arrival in Mauritius
Copy of Residence Permit
Copy of Marriage Certificate (if any)
I, the undersigned, hereby declare that the above information is correct in all respects.
Date:
..........................................................
Signature:
.......................................................
*:In accordance with Tourism Act 2006, the Competency Test Panel may exempt any person from the whole or part of the Competency Test.
Tourism Authority
1st Floor, New Victoria House, CNR Line Barracks & Saint Louis Streets, Port Louis.
Tel - 213 1740
Fax: 213 1745
Hotline: 8910
E-mail: tourism.authority@intnet.mu Web: http://www.tourism-authority.mu
App. No. :
Licence No. :.......................................................
Surname:
Date of Birth:
SIGHT
Normal
Defective
visual fields
Right eye
Colour vision
Normal
Defective
Not tested
HEARING
Normal
Defective
(speech and whisper test)
Right ear
Left ear
TO BE COMPLETED BY MEDICAL PRACTITIONER
On the basis of the examinee's personal declaration and my diagnostic test,
I declare the examinee (tick where applicable)
fit
to be issued with a Certificate of Competency for pleasure craft skipper's
unfit
to be issued with a Certificate of Competency for pleasure craft skipper's
To be filled by medical Practitioner if examinee is found to be
unfit
(reasons)
.................................................
Signature of Medical Practitioner
.......................................................
Printed Name
............................
Date
Applicant to sign in presence of Medical Practitioner
........................................................
Signature of applicant
