Application Form For Seafarers

* APPLICATION FOR OTHER POSITION (IF ANY)   PHOTO

 

1. PERSONAL DETAILS
   
* TITLE  MR/MRS/MISS * Sex Male Female
* SURNAME
* FIRST NAME * THIRD NAME
* DATE OF BIRTH * PLACE OF BIRTH
* NATIONALITY * MARITAL STATUS
* COLOUR OF EYES * COLOUR OF HAIR
* MOTHER’S NAME * FATHER’S NAME
* MOTHER’S MAIDEN NAME
* HEIGHT (CM) * WEIGHT (KG)
* NEAREST INTERNATIONAL AIRPORT:

2. Address

  

ADDRESS (TEMP.) FROM/TO:
 
* NO & STREET * NO & STREET
* CITY   * CITY
* POST CODE * POST CODE
* COUNTRY * COUNTRY
* TEL. NO. * TEL. NO.
* MOBILE * MOBILE
* E-MAIL * E-MAIL
* FAX   * FAX  

3. NEXT OF KIN

  

 
 
* FULL NAME * RELATIONSHIP
* ADDRESS
* CITY * COUNTRY
* TEL. NO. * FAX NO.
* MOBILE    

4. CHILDREN

  

 
 
FULL NAME OF CHILD DATE OF BIRTH SEX  
M F
M F
M F
M F
M F

5. TRAVEL DOCUMENTS

  

 
           
* TYPE * DOCUMENT NO. * ISS.DATE * EXP. DATE * ISS. BY (AUTHORITY) * PLACE OF ISSUE
* PASSPORT
* SEAMAN BOOK
* OTHER SEAMAN BOOK
* US C1/D VISA
   OTHER VISAS

6. BANK ACCOUNT INFORMATION

 

 
 
BANK NAME BRANCH
BANK ADDRESS
CITY COUNTRY
SORT CODE ACCOUNT NO
BANK SWIFT CODE BANK TEL. NO
ACCOUNT OWNER’S NAME
ACCOUNT OWNER’S ADDRESS

7. EDUCATION

 

 
 
  * From * To

* SCHOOL NAME

  

* SCHOOL NAME

  

8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

 
CERTIFICATE NAME NUMBER ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT

DANGEROUS CARGO ENDORSEMENT NUMBER ISSUE DATE EXPIRY DATE    
PETROLEUM    
CHEMICAL    

GAS

    

9. LANGUAGES

       

 

    
                 
ENGLISH FLUENT GOOD FAIR POOR
GERMAN FLUENT GOOD FAIR POOR
FRANCH FLUENT GOOD FAIR POOR
SPANISH FLUENT GOOD FAIR POOR
ITALIAN FLUENT GOOD FAIR POOR
RUSSIAN FLUENT GOOD FAIR POOR
MARLIN’S TEST / LEVEL ISSUED DATE RESULT % ISSUED BY(AUTHORITY) ISSUED AT

10. HEALTH CERTIFICATES & VACCINATIONS

 
FLAGE STATE * NUMBER * ISSUE DATE * EXPIRY DATE * ISSUED BY (AUTHORITY) * ISSUED AT

* INTERNATIONAL
* LIBERIAN
* ST. VICENTE
* PANAMANIAN
   FLAGE STATE * NUMBER * ISSUE DATE * EXPIRY DATE * ISSUED BY (AUTHORITY) * ISSUED AT
* YELLOW FEVER

11. SAFETY CLOTHING

  

 
 
* BOILERSUIT SIZE * BOOTS SIZE

12. MARINE COURSES

 
COURSE NAME NUMBER ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY) ISSUED AT

PERSONAL SURVIVAL
BASIC FIRE FIGHTING
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID
MEDICAL FIRST AID
MEDICAL CARE
PERS.  SAFETY & SOC. RESP
PROF. IN SURVIVAL CRAFT & RESCUE BOATS
FAST RESCUE CRAFT
G.M.D.S.S.
A.R.P.A. (Management level)
RADAR OBSERVATION
HAZMAT
OIL TANKER
ADVANCED OIL TANKER
CHEMICAL TANKER
ADVANCE CHEMICAL TANKER
GAS TANKER
ADVANCE GAS TANKER
CRUDE OIL WASHING
INERT GAS PLANT
ISM CODE
SHIP SECURITY OFFICER
BRIDGE TEAM MANAGEMENT
DP INDUCTION
DP SIMULATOR
BRIDGE / ENGIINE ROOM RESOURCE MANAGEMENT.
SHIP HANDLING
INTERNAL AUDITORS COURSE
ENGINE ROOM MANAGEMEN
ECDIS
PREVENTING COMBATING MARINE POLLUTION
ADVANCED COMMUNICATION
PROFICIENCY OF SECURITY AWARENESS TRAINING SEAFARERS
MARINE RADAR AND AUTOMATIC RADAR AIDS
PROFICIENCY IN PERSONAL SURVIVAL TECHNIQUES  
COMMUNICATION
PERSONAL SAFETY AND SOCIAL RESPONSIBILITIES
INTERNATIONAL CODE FOR THE SECURITY OF SHIP AND PORTS
BACHELOR DEGREE IN MARITIME TRANSPORT- NAUTICAL TECHNOLOGY
OTHER COURSES  
   
   
   

13. SPECIALISED EXPERIENCE

  

 

    
 
TYPE From To COMMENTS

NEW BUILDING

  
SPECIALISED PROJECTS  
OFFSHORE EXPERIENCE  

SHORE EXPERIENCE

  

COMPLETE SEA – SERVICE DETAILS ( LAST VESSELS FIRST )

NAME:   RANK:     AVALIABILITY DATE:
                                     
COMPANY NAME   RANK   VESSEL NAME   SIGNED ON   SIGNED OFF  

PERIOD IN MONTHS

(eg 4.2)		   TYPE OF VESSEL   D.W.T.  

ENGINE TYPE

( ENGINEERS ONLY)		   BHP   KW
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   

REFERENCE CONTACT DETAILS

 

      
 

COMPANY NAME

    
ADDRESS    
PHONE NO.    
FAX/E-MAIL    
CONTACT PERSON    
I declare that the information I have given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are genuine, given and sign by persons whose names appear on them.
    DATE   SIGNATURE  

 

      

Officer Application Form

  

 

 Ref .No  
  (For Official Use)
Medical History        
Have you ever signed off from a ship due to medical reasons?    
Yes          
No        
       
Name of Vessel Date of occurrence  (dd-mmm-yyyy)
Brief Description Of illness/Injury/Accident
Details
Have you ever suffered from any ailment or disease in the past that is likely to render you unfit for sea service or likely to endanger the health /well being of others onboard?  
Yes          
No        
       
Do you have any bodily defects or deficiencies?  
Yes          
No        
       
Are you currently suffering from any ailment or disease that is likely to render you unfit for sea service or likely to endanger the healthy /well being of others onboard?  
Yes          
No        
       
Are you addicted to alcohol or drug of any kind?  
Yes          
No        
       
Are you suffering from an ailment that requires you to be on a long -term treatment/medication?  
Yes          
No        
       
Have you ever deported or banned from entering any country?  
Yes          
No        
       
Have you ever been convicted of a criminal or drug offence or have any pending offences?  
Yes          
No        
       
Do you have any obligations towards your current/previous employers?  
Yes          
No        
       
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief; further, that no certificate of competency or License issued to me has ever been Revoked or Suspended. I also certify that my medical history contained above is true and any false statement or undisclosed Material information about past illness or injury will disqualify me from any employment benefits and claims.
    dd-mmm-yyyy (Format) Signature