COMMONWEALTH MARITIME SECURITY IDENTIFICATION CARD (CMSIC) APPLICATION FORM

Application Identification Number
ESP/0000 _ _ _ _
(Issuing Body Use Only)
COMMONWEALTH MARITIME SECURITY IDENTIFICATION CARD (CMSIC)
APPLICATION FORM
PART A: Applicant Information
(Please complete all of Part “A” ONLY)
EPSL Access Card No. _ _ _ _
Application Type: (select one box only and then select duration)
Standard MSIC - I am applying for a CMSIC for the first time. Duration - 3 Years ($335) 5 Years ($680)
Provisional MSIC - I am under 18 years of age.($282) Past Provisional MSIC(if applicable) ______________ Expiry Date _ _/_ _/_ _ _ _
Renewal - I am renewing My Standard MSIC. ($232) or ($295) (MSIC No.) ______________ Expiry Date _ _/_ _/_ _ _ _
NAME(S):
Current
Replacement - I am replacing a Lost/Stolen MSIC. ($86) (MSIC No.) ______________ Expiry Date _ _/_ _/_ _ _ _
ASIC based - I am the holder of a current ASIC. ($152) (ASIC No.) ______________ Expiry Date _ _/_ _/_ _ _ _
Note: Payment is required before Application will be processed
Sex Title Surname Given Name 1 Given Name 2 Given Name 3
M MR MAGEBA SIYABONGA NKULULEKO
If you have had previous names enter the details below. Type of previous Name(s): B- Birth Name, M- Maiden Name, A- Alias, O- Other
Type*
Previous 1
Previous 2
Date of Birth Place of Birth: Country Place of Birth: City/Town Place of Birth: State
- - - - - -
-
25
- / 02 / 1980
SOUTH AFRICA MSELENI SOUTH AFRICA
CITIZENSHIP COUNTRY
Enter your country of citizenship
Complete this section if you are not a citizen of Australia, European Citizen and USA
PASSPORT DETAILS
Passport
Number
Place Issued
Or
ID Number
SOUTH AFRICAN
SOUTH AFRICA
8002255710087
Date Issued
05 05 2014
- - / - - / - - - -
National Identification Card Number –
8002255710087
A04159525
Passport Number –-------------------------------------------
8002255710087
Expiry Date: -
04
- / - 05 - / - 2024 - - -
Name Of Cruise Line Company –-- HOTEL & CRUISE PORT OF AMSTERDAM NETHERLANDS
Position
FLOOR SUPERVISOR
Salary
EU 5,200
Page 1

Commonwealth Maritime Security Identification
Card (MSIC)
Application Form (continued)
CURRENT RESIDENTIAL ADDRESS:
Unit # Street # Street Name Suburb / Town Postcode
857 UMBILO DURBAN 4001
State Country Date resided here from
S.A SOUTH AFRICA
- 20- / 02 - - / - 2003 - - -
* If you have lived at this address less than 10 years – provide details of all previous
addresses below for up to 10 years in total to date.
CURRENT POSTAL ADDRESS: As Above -
Unit # Street # Street Name Suburb / Town
State Country Postcode
PREVIOUS RESIDENTIAL ADDRESS (1):
Unit # Street # Street Name Suburb / Town Postcode
State Country Date from
Date to
- - / - - /- - - - - - / - - /- - - -
PREVIOUS RESIDENTIAL ADDRESS (2):
Unit # Street # Street Name Suburb / Town Postcode
State Country Date from Date to
- - / - - / - - - - - - / - - /- - - -
PREVIOUS RESIDENTIAL ADDRESS (3):
Unit # Street # Street Name Suburb / Town Postcode
State Country Date from Date to
- - / - - /- - - - - - / - - /- - - -
Page 2

Commonwealth Maritime Security Identification Card (MSIC)
Application Form (continued)
YOUR CONTACT DETAILS:
Home Phone: O Work Phone: O Mobile Phone:O
( +2735) 5741036 ( 031 ) 204 9100
0794705428
Email:
snmageba20@gmail.com
₃₃ Tick preferred phone number
EMPLOYER DETAILS:
Company Name
BIDFREIGHT PORT OPERATIONS
Employer Contact Person
Yoga Thinnasagren
Address 1ST FLOOR MILLWEED HOUSE
169-175 MAYDON WHARF ROAD
DURBAN
4001
Email yoga.thinnasagren@bidports.co.za
Employer Phone
031 2742400
Employer Fax
031 205 4116
Acknowledgement
I understand that I am applying for a security identification card for the maritime industry. The
information that I have provided in this application is correct to the best of my knowledge.
I understand that my personal information will be used by Commonwealth Office to co-ordinate a
background check through the Commonwealth Security Intelligence Organisation (CSIO), CrimTrac
and the Department of Immigration and Citizenship (CIAC), where necessary.
I declare that I have completed all the assessment requirements of the MSIC Induction and
understand my responsibilities as the holder of a MSIC.
Signature
Date
15/05/2014
All records held by EPSL under the CMSIC Plan shall be secured in accordance with
the Commonwealth Privacy Act 1988 and other relevant Commonwealth law. Access
will not be granted for other than CMSIC relevant purposes.
FM299
Page 3

Commonwealth Maritime Security Identification Card (MSIC)
Application Form (continued)
Date: _ _ / _ _ / _ _ _ _
Page 4
PART C: CMSIC Awareness Induction (Issuing Body Use Only)
Induction Officer:________________________ Date of Induction: _ _ / _ _ / _ _ _ _
Officer’s Signature:_______________________
PART E: Card Issue
Authorisation to Issue
Signed:__________________________________
(Issuing Body)
Collected by Applicant
Signed:__________________________________
(Applicant)
Type of Photographic Identification produced by applicant on collection of CMSIC:
Application Identification Number
ESP/000_ _ _ _
(Issuing Body Use Only)
Date: _ _ / _ _ / _ _ _ _
Date: _ _ / _ _ / _ _ _ _
___________________
Page 4