Application for Replacement of Certificates (FORM NMA-5_REP.2018.Rev.0) 1. PARTICULARS OF APPLICANT Name (In Block Letters, as in identity card/passport) NRIC / Passport No. Address Telephone No. 2. PARTICULARS OF REQUESTED CERTIFICATES FOR REPLACEMENT Type of Certificate Certificate No. Date of Issue Date of Expiry 3. REASON(S) FOR REQUESTING REPLACEMENT Provide brief description / account / explanation of how the certificates were misplaced / damaged / destroyed etc. 4. DOCUMENTS SUBMITTED AS EVIDENCE Police Report Statutory Declaration Damaged Certificate Others: *Tick as appropriate 5. DECLARATION OF APPLICANT I declare that the particulars and information furnished above are correct and true to the best of my knowledge and belief. I undertake that if I find the lost certificate(s), I will return the certificate(s) to the Nauru Maritime Administration. Date: Signature of Applicant:
Application for Replacement of Certificates (FORM NMA-5_REP.2018.Rev.0) 1. PARTICULARS OF APPLICANT Name (In Block Letters, as in identity card/passport) NRIC / Passport No. Address Telephone No. 2. PARTICULARS OF REQUESTED CERTIFICATES FOR REPLACEMENT Type of Certificate Certificate No. Date of Issue Date of Expiry 3. REASON(S) FOR REQUESTING REPLACEMENT Provide brief description / account / explanation of how the certificates were misplaced / damaged / destroyed etc. 4. DOCUMENTS SUBMITTED AS EVIDENCE Police Report Statutory Declaration Damaged Certificate Others: *Tick as appropriate 5. DECLARATION OF APPLICANT I declare that the particulars and information furnished above are correct and true to the best of my knowledge and belief. I undertake that if I find the lost certificate(s), I will return the certificate(s) to the Nauru Maritime Administration. Date: Signature of Applicant:
Form-NMA-5_REP.docx