MODEL FOR THE SINGLE DOCUMENT COMBINING UNION CERTIFICATES OF QUALIFICATION AND THE SERVICE RECORD BOOK
ANNEX IISupplementary provisions
ANNEX II MODEL FOR THE SINGLE DOCUMENT COMBINING UNION CERTIFICATES OF QUALIFICATION AND THE SERVICE RECORD BOOK Page 1 of the model Name of country Service record book combined with certificates of qualification Identification of the holder 2D barcode 1. Name(s) of the holder: 2. First name(s): 3a. Date of birth: 3b. Place of birth: 4. Crew member identification number: 5. Photo Identification of the service record book 1. Serial number: 2. Date of issue: 3. Issuing authority: 4. Signature and stamp of issuing authority: 5. Serial number of former service record book: SRBXXXXSSSS Page 2 of the model European Union certificates of qualification and certificates of qualification issued according to the Regulations for Rhine Navigation Personnel as apprentice, deckhand, boatman, able boatman and helmsman Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: SRBXXXXSSSS Page 3 of the model Other certificates concerning qualifications relevant for inland navigation Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: Title of certificate: ________________________________________ Fitness related mitigation measures and restrictions: Serial number: Date of issue: Date of expiry: Issuing authority: Signature and stamp of issuing authority: SRBXXXXSSSS Page 4 of the model Service time Service time on board, name of craft : Unique European vessel identification number or other official craft number: Type of craft ( 1 ) : State of registration: Length of craft in m ( *1 ) /number of passengers ( *1 ) : Owner (name and address): Holder assumed service as ( 2 ) : Holder assumed service on (date): End of service (date): Boatmaster (name and address): Place, date and signature of boatmaster: Service time on board, name of craft: Unique European vessel identification number or other official craft number: Type of craft State of registration: Length of craft in m ( *1 ) /number of passengers ( *1 ) Owner (name and address): Holder assumed service as: Holder assumed service on (date): End of service (date): Boatmaster (name and address): Place, date and signature of boatmaster: SRBXXXXSSSS Pages 5 to 22 as page 4 Page 23 of the model Navigation time and stretches of inland waterways sailed over last 15 months Year: … The number of days navigated must be consistent with the navigation time entered in the logbook! Name of craft or unique European identification number or other official craft number journey from via to (km) Start of journey (date) Days of interruption End of the journey (date) Total number of navigation days Signature of boatmaster A B C D E F G 1 2 3 4 5 6 7 8 9 10 Complete document ☐ yes ☐ no ☐ Doubts at line(s):________ Doubts have been eliminated by presenting ☐ (parts of) the logbook ☐ other official documents Space reserved for the competent authority To be completed by the authority: total number of navigation days taken into consideration from this page Validation mark of the competent authority Presented on (date) ___________ Signature and stamp of the authority SRBXXXXSSSS Pages 24 to 55 as page 23 Headings of columns A to G not printed on those pages Page 56 of the model Without content Instructions for the issuing authorities Identification of the holder 1. Current family name(s) of the holder 2. Current first name(s) of the holder Names shall be those appearing on the ID card or passport of the person concerned and shall be entered in UNICODE. If a name is spelled differently in UNICODE and in ASCII, there shall also be transcribed in ASCII in brackets. 3a. Date of birth (dd/mm/yyyy) 3b. Place of birth (city) 4. Crew member identification number of the holder (CID) as attributed in the database referred to in Art. 25(2) of Directive (EU) 2017/2397 of the European Parliament and of the Council. Identification of the service record book The serial number of the service record book shall consist of: — the crew member’s CID; — the type of document as coded in the European Reference Data Management System (ERDMS); the issuing authority as coded in ERDMS; — the number of the document in 4 digits. The serial number of the service record book without the part on CID shall be repeated in the lower section of each page. Certificates of qualification The title of the issued certificate shall be inserted (in caps font) by the relevant competent authority. It shall be complemented by the following numbers in brackets, as appropriate: ‘(2)’ for Helmsman, ‘(3)’ for Able boatman, ‘(4)’ for Boatman, ‘(5)’ for Deckhand and ‘(6)’ for Apprentice. As regards the Union certificates of qualifications, the title ‘European Union certificate of qualification in inland navigation’ accompanied by the relevant qualification shall be indicated for example ‘European Union certificate of qualification in inland navigation – Able boatman (3)’. As regards certificates of qualifications issued in accordance with the Regulations for Rhine Navigation Personnel, the title ‘CCNR certificate of qualification’ accompanied by the relevant qualification shall be indicated for example ‘CCNR certificate of qualification – Able boatman (3)’. Physical characteristics of the document Colour: cover: light blue Pantone 290C; white background of inner pages Format A5 according to ISO 216 Example of a filled in entry for service time Service time on board, name of craft: UNTERWALDEN Unique European vessel identification number or other official craft number: 07000281 Type of craft 1 : State of registration: CH Length of craft in m*/ number of passengers * 105 m Owner (name and address): TSAG, Hauptstrasse 55, CH-4127 Riehen, Basel-Stadt Holder assumed service as 2 : 3 Holder assumed service on (date): 22.10.1995 End of service (date): 22.11.1996 Boatmaster (name and address): K. Huber, Rheinstrasse 55, D-76497 Wintersdorf Place, date and signature of boatmaster: Rotterdam, 20.11.1996 K.Huber Example of a filled in page for navigation time and stretches sailed Navigation time and stretches of inland waterways sailed over last 15 months Year: 2015/2016 The number of days navigated must be consistent with the navigation time entered in the logbook A B C D E F G 1 07000281 Rotterdam (999,90)Mainz (500,00) Wien (1930,00) 22.11.15 11 17.12.15 15 Signature Huber 2 07000281 Wien (1930,00) Mainz (500,00) Basel (169,90) 20.12.15 4 4.1.16 12 Signature Huber 3 07000281 Basel (169,90) Rotterdam (999,90) 6.1.16 0 10.1.16 5 Signature Huber 4 07000281 Rotterdam (999,90) Antwerpen (20,00) Basel (169,90) 13.1.16 1 23.1.16 10 Signature Huber 5 07000281 Basel (169,90) Antwerpen (20,00) 25.1.16 0 29.1.16 5 Signature Huber 6 07000281 Antwerpen (20,00) Basel (169,90) 1.2.16 0 7.2.16 7 Signature Huber 7 07000281 Base (169,90) Mainz (500,00) Bratislava (1867,00) 9.2.16 5 22.2.16 9 Signature Huber 8 07000281 Bratislava (18657,00) Regensburg (2376,30) 27.2.16 0 2.3.16 5 Signature Huber 9 07000281 Regensburg (2376,30) Mainz (500,00) Rotterdam (999,90) 3.3.16 0 9.3.16 7 Signature Huber 10 07000281 Rotterdam (999,90) Basel (169,90) 12.3.16 0 17.3.16 6 Signature Huber Complete document ☑yes ☐ no ☐ Doubts at line(s)__________ Doubts have been eliminated by presenting ☐ (parts of) the logbook ☐ other official documents Space reserved for the competent authority To be completed by the authority: total number of navigation days taken into consideration from this page 81 Validation mark of the competent authority Presented on (date) 15.04.16 Signature and stamp of the authority SRBXXXXSSSS ( 1 ) For type of craft, always indicate if type C or G tanker, large convoy or if craft using LNG as fuel ( *1 ) Delete if not applicable ( 2 ) Holder assumed service as’: the function must be numbered according to instruction for keeping the logbook