Application Form

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Section 1 / Position
Position Applied for
Lowest Position Acceptable
Date of Availability
Minimum salary or day rate
Section 2 / Personal Details
Family name / Surname
First Name / Given Name
Date & Place of Birth
Nationality
Permanent Address
Present Address
Present Contact Number
SKYPE ID (24 hrs)
Mobile Number
Email Address
Nearest Airport
Section 3 / Passport, Seaman’s book (Discharge book ) and Visas
Passport / Seaman’s book / Visas
Number
Issued place
Date issued
Date of expiry
Section 4 / Next of Kin
Full Name / Relationship
Address
Contact Numbers
Section 5 Highest Certificate of Competency / Licence Held
Class / Grade / Issuing country / Certificate No. / Date issued / Date of expiry / Details of any limitations
Section 6 Courses Attended and Certificates Obtained
Name of Course / Certificate / Certificate No. / Issued place / Issued date / Date of expiry
Personal survival techniques
Fire prevention and Fire fighting
Elementary first aid
Personal safety and socialresponsibility
Proficiency in survival craft & rescue boats
Advance fire fighting
Proficiency in medical first aid
Medical care
Bridge team management
Radar/ ARPA
GMDSS
ECDIS
Engine team Management
High voltage
Security awareness
Security training for seafarers with designated security duties (SDSD)
Ship Security Officer (SSO)
Ship safety officer
Medical Fitness Certificate
Other certificates:
Tanker certificates
Tanker Familiarization
Oil Tanker Advanced
Chemical Tankers Advanced
Liquefied Gas Tankers Advanced
Crude oil washing (COW)
Inert gas system (IGS)
Offshore certificates
HUET
BOSIET
Proficiency in fast rescue boats
Dynamic Positioning Induction Course
Dynamic Positioning Simulator Course
Dynamic Positioning Operators Certificate
Dynamic Positioning Maintenance course
Section 7 General
Have you ever been the subject of a court of enquiry or involved in a maritime accident
Have you ever had a professional licence suspended or revoked
If yes to any of above then please full details below or on separate sheet of paper
Section 8 References ( Last 3 Recent Employers)
Name of company
Person in charge/ position
Tel No
Email
Name of company
Person in charge/ position
Tel No
Email
Name of company
Person in charge/ position
Tel No
Email
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
Signed: Date:
Section 9 Record of Sea Service (All Dates to be entered as dd/mm/yy)
STARTING FROM LAST VESSEL FIRST
Vessel name / Type of Vessel / DWT or
GT / Main engine type / KW / DP system / Rank / Sign on date / Sign off
date
Company name