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Application Form for Individual Membership (Please type or complete in black ink, using BLOCK LETTERS)

Family Name:___________________________________________________ First Name(s):___________________________________________________ Nationality:___________________________________________________ Date & Place of Birth:___________________________________________________

Permanent Address:___________________________________________________ ___________________________________________________ ___________________________________________________

Phone:___________________________________________________ Fax:___________________________________________________ Email:___________________________________________________

Master Mariner‘s Certificate/Licence No.:___________________________________________________ Date & Place of Issue:___________________________________________________ Issuing Authority/Government:___________________________________________________

Other Qualifications:___________________________________________________ Number of years in command of sea-going ships:___________________________________________________ Are you a member of your national association?___________________________________________________ National association name & address / website:___________________________________________________ Brief details of career stating current trade:___________________________________________________

Brief details of general education:___________________________________________________ Details of nautical education:___________________________________________________ Signature: _________________________DDate:____________________

( Please note: This form must be posted to IFSMA as your original signature is required ! )

IFSMA Application Form for Individual Membership  
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