◆ SpookStack

Lee UTOST DOME TS" 2 a - -PRIW? ALL ENTRIES @ DAT ale IS Et A I SPE I i —-—_ Name in full: . sin Povne C permanent home address: Box 1t1é Cut Saak enn TAVvA Your rating on last vessel on which you were employed: Date and Port signed on that vessels ATE: 14 a! 2PORT: SEAT S&ATTS E ee Number of other lost certifica certificates: ~ (A, B, GC, D& E certificates) Number Ke srchant Mariner's document or ertificete of Identification, Myumber Ze £EBF _ i, an ht wht port weré the lost documents iscued? VArious ee On what date were lost document. issued? ' VAC O“uS, atings shown on lost CERTIFTCATES OR MERCNANT MARTEER'S DOCUMcNT: FLO OLE. Ade EGR Are the documents for which duplicates are requested, or any endorsement thereon, currently revoked, susvended, or voluntarily surrendered? rit . "LOST DISCHARGES" i one) NO NOT Fill in snaces oelow if you are ROt filing for lost discharges. SEE “REVERSE STDE DATE SIGUED DATE SICYED RATING ON RATE RAPS OF SHTP Est PLT, ON VESSEL SSEL OVF VESSEL | VESSEL PORT OF RESCHARGE “TA. Cs _peguested Thar Z ge Svasished ff cociplere pecors bE Sor d of 44 9 TER SELES. Seon aed Zaeladinp leit ts of Malad rag a ~Apiprsniee stole 2 oes charge __/ statin nese AhGEe, p PME SEY s b7C