MARINE DEPARTMENT
THE GOVERNMENT OF THE HONG KONG SPECIAL ADMINISTRATIVE REGION
香港特別行政區政府海事處Application for Dispensation of Manning
申請豁免船員配備

To:
致:Shipping Division, Marine Department
海事處船舶事務科(E-mail 電郵: exemption@mardep.gov.hk, Fax 傳真: (852) 2545 0556)

I hereby apply for dispensation of a seafarer with details described below:
本人現申請豁免下述船員 ，詳情如下：(Note: Incomplete applications will not be processed

注意：如未能提供足夠資料，恕不接受申請)

Name of Applicant:
申請人姓名

Position:
職位

Name of Company:
公司名稱Company Address:
公司地址Tel. No. :電話

Office:辦公室Mobile:
手機Fax No. :傳真

E-mail:電郵

Signature of Applicant:
申請人簽名

Date:
日期
Particulars of Ship 船舶資料

Name of Ship:
船名Type of Ship:
船舶類型

IMO Number:
國際海事組織編號

Call Sign:
呼號

Date of Keel was Laid:
龍骨安放日期Gross Tonnage:總噸位Classification Society:
船舶所屬船級社

Ship’s Current Location:
船舶現時位置

Date & Time of Sailing:
開航日期及時間

Next Port of Call:
Date & Time:
下一港口名稱
到達日期及時間

MD 605 (2022/04)

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1. Information of seafarer to be dispensed (Relevant grade of the searfarer shown in MSMC must be specified,e.g. Deck Officer Class 2)
申請豁免船員的資料(必須說明相關船員在最低安全人手編配證明書的等級，例如甲板高級船員第 2級)a) Name of seafarer 船員姓名：b) Position 職位：c) Grade in MSMC 在最低安全人手編配證明書的等級:d) Date of sign off 離船日期:
Note 注意：
Copies of the following documents must be attached to this application form:
以下文件複印本必須連同此申請表一併遞交:a)b)c)

Minimum Safe Manning Certificate 最低安全人手編配證明書Crew List 船員名單Hong Kong Licence of the above seafarer, if any 上述船員的香港執照，若有

2. Reason(s) for the dispensation 需要豁免的原因:

3. a) Arrangement for new replacement 接班船員的安排b) Details of voyage from port of sign off to the port where the new replacement will join the ship (includingdate、name of port and country) 由船員離船港口前往接班船員的港口的詳細航程 (包括日期、國家和港口名稱)：4. Others (please specify) 其他 (請說明)：Note: Please use separate sheets for additional information if needed 如有需要，請使其他紙張提供資料

MD 605 (2022/04)

2收集個人資料聲明
1.
目的海事處會使用透過本申請表所獲得的個人資料作下列用途：

Personal Data Collection Statement
1.
Purposes of Collection
The personal data provided by means of this form will beused by Marine Department for the following purposes:(a) 辦理有關審批你在本申請表中所提出的申
請的事務；(a) activities relating to the processing of your application inthis form;(b) 方便海事處與你聯絡；(b) facilitating communication between Marine Department
and yourself;(c) 藉此協助其他政府決策局和部門執行其他
法例和規例；(d) 成功申請人的有限個人資料會用於海事處的互聯網網頁以供第三者查證本處所發出的證書；以及(c) assisting in the enforcement of any other Ordinances andRegulations by other Government Bureaux andDepartments;(d) limited personal data of successful applicants may beused via the Marine Department’s Internet web site forverification of the issued certificate by any third party; and(e) 供作統計及研究用途，但所得的統計數字
或研究成果，不會以能辨識各有關的資料 當事人或其中任何人的身份的形式提供。

(e) for statistics and research purposes on the condition thatthe resulting statistics or results will not be made available ina form which will identify the data subjects.

2.
獲轉交資料的部門╱人士
你透過本申請表所提供的個人資料會向其他
政府部門、決策局及有關機構，以作上述第 1段所列的用途。

2. Classes of Transferees
The personal data you provided by means of this form may
be disclosed to other Government Bureaux and Departments
for the purposes mentioned in paragraph 1 above.

3.
索閱個人資料根據《個人資料（私隱）條例》（第486章），資料當事人有權要求查閲及改正在此申請表提供的個人資料。如須查閲或改正此申請表的個人資料，請與海事處貨船安全組聯絡。

3. Access to Personal Data
You have a right of access and correction with respect topersonal data as provided for in Sections 18 and 22 andPrinciple 6 of Schedule 1 of the Personal Data (Privacy)
Ordinance. Your right of access includes the right to obtain acopy of your personal data provided by this form.

4. 查詢有關透過本申請表收集的個人資料的查詢，包括索閱及修正資料，應寄往：

4. Enquires
Enquiries concerning the personal data collected by meansof this form, including the making of access and correction,
should be addressed to:

香港
中環統一碼道38號
海港政府大樓24樓
海事處貨船安全組主管

Officer-in-charge
Cargo Ships Safety Section
Marine Department
24/F, Harbour Building
38 Pier Road, Central
Hong Kong.

MD 605 (2022/04)

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