第二十二号の四の二書式(第七十七条の六関係) (日本産業規格A列4番)
危険物等取扱責任者適任証書
Certificate of Proficiency as Person Responsible for Handling Dangerous and Other Substances
1978年の船員の訓練及び資格証明並びに当直の基準に関する国際条約に基づく証明書 Certificate Issued under the Provisions of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended
日本政府は次のとおり証明する。
The Government of Japan certifies the following:
| 証明書の種類 | |
| Proficiency as | |
| Comply with | of the STCW Convention, as amended |
| Limitations applying (IF ANY) | |
証書番号
Certificate No. | |
交付年月日
Issued on | 有効期間
Valid until |
船員ID/Mariner's ID
姓/Surname
(旧姓/Former surname)
名/Given name
生年月日/Date of birth
性別/Sex
国籍/Nationality
本籍/Registered
署名/Signature