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 ! )