Correct to the Best of My Knowledge & Belief

Dear Sirs,

I decleared that all documents are genuine and all information given are

correct to the best of my knowledge & belief.

Yours faithfully

Signature
Rank Applied For: / Availability Date:
Application Date: / Application Place:
First Name: / Other Names:
Religion: / Martial Status:
Nationality: / N.I.C. No.
Date of Birth: / Place of Birth:
Father’s Name: / Mother’s Name:
Wife Name: / Date Married:
Mailing Address: / Permanent Address:
Telephone/Fax/E-mail: / Telephone/Fax/E-mail:
Nearest Main Airport:
NEXT OF KIN / FAMILY
N.O.K. Name: / Relation:
N.I.C. No: / Telephone/Fax/E-mail:
Address:
No. / Children Name / Sex / Date of Birth
1.
2.
3.
4.
Language information
English: / Italian: / French:
Spanish / German: / Others:
(To fill with V=Very Good / G=Good / F=Fair / P=Poor / N=No)

ETHNIC ORIGIN

African / Asian / Caribbean / Oriental / UK/Eire / Other European / Other (please spec)
TRAVELLING INFORMATION
Country / Number / Issue Date / Expiry Date / Issued At
Passport: *
National Seaman Book:
Foreign Seaman Book:
US C-1 Visa
US D Visa
US B1 B2 Visa:
Other Visa:
* Passport should be valid for 6 months / Attach Photocopies of title and all entered pages
General & further education
Dates / School & Colleges Attended / Examinations Passed & Certificates Obtained
From / To
Details of apprenticeship / cadetship
Company: / College Attended:
Date App/Cadet / Country
Commenced:
Date App/Cadet
Completed: / Final Attainment:
certificate of competency / licences held
Certificate / License / Grade / Country
of Issue / Certificate Number / Date Passed / Place Issued / Issue Date / Expiry Date
Competency
Flag Equivalent
Flag Equivalent

Attach Photocopies all pages

MANDATORY CERTIFICATES
(For Subjects already included in another certificate, enter N.A.)
Course Undertaken/Endorsement / Certificate Number / Issued By / Place Issued / Issue Date / Expiry Date
For Freshers & Ratings (Minimum for all seafarers, unless superceded by a higher grade)
Personal Survival Techniques
Fire Prevention and Fire Fighting
Elementary First Aid
Personal Safety and Social Responsibility
For All Officers
Survival Craft, Rescue Boats
Advanced Fire Fighting
Medical First Aid
For Masters & Chief Mates
Take Charge of Medical Care
For Watchkeeping Ratings
Cert (Rating) part of Navigational Watch OR
Service Cert (Rating) part of Navigation Watch
Cert (Rating) part of Engine Watch OR
Service Cert (Rating) part of Engine Watch
Ancillary Certificates for Deck Officers
G.M.D.S.S. †
Radio Telephony Certificate ††
Radar Simulator
Electronic Navigation (Systems / Aids) *
Navigation Control Course (NCC)
Automatic Radar Plotting Aids (ARPA)
FOR TANKERS
* Tanker Familiarization (PET/CHEM/GAS) / **
Advanced Tanker Safety (PET/CHEM/GAS) / **
DCE (PET/CHEM/GAS) / **
† Optional till January 2002, unless required by Owners/Flag state.
†† Where required for vessel of lower tonnage restricted trading only carrying this equipment for long range Communication.
* Minimum required for all Ratings & Junior Officers not holding Cert/DCE below.
** Strike off which not applicable, and indicate details separately if more than one.
additional qualification
Course Undertaken/Endorsement / Certificate Number / Issued By / Place Issued / Issue Date / Expiry Date
Efficient Deck Hand
Ship Board Safety Officer
Bridge Team / Resource Management
Electronics for Engineers
Programme Maintenance System (PMS)
ISM Course
Ship Manned Module Course
Engine Plant Simulator Course
Boiler Water Treatment
Instrumentation & Control
Vibration Monitoring
Dynamic Positioning
Gas Welding
Electric Welding
Marine Computer Application
Industrial Management Course
Ship Simulator & Bridge Team work
Maritime Law for Ships' Officers

Attach Photocopies all pages

specialised experience tankers
VESSEL / SYSTEM / EQUIPMENT / Months / VESSEL / SYSTEM / EQUIPMENT / Months
Multi-Grade Cargoes / Remote Pumps / Valves
Ship to Ship Transfers / Deck Cranes / Derricks
Closed Loading / Steam Winches
Lube Oil Cargoes / Hydraulic Winches
COW Systems / Eductor System
Free Flow Systems / Contrifugal Cargo Pumps
SBT / Submerged Pumps
Cold / Hot Washing / Double Hull Vessels
Auto Ullage Guages
specialised experience others / general
VESSEL / SYSTEM / EQUIPMENT / Months / VESSEL / SYSTEM / EQUIPMENT / Months
GMDSS / Instrument Air System
APRA / Domestic Refrig system
Integrated Bridge Systems / Dry Dock
Steam Turbines / Air compressors
Water Tube Boilers / Emergency Generators
Hydraulics / Electronics
Machine Tool Operations / Automation
Machine Assembly / Fire Detection Systems
UMS Operation / Switch Gear
Bridge Control System / Computer Control
Controllable Pitch Propeler / Pre-Planned Maintenance
Welding Gas / Electric / Anchor Handling Tug
AC Power Plant / Maintenance Boat
DC Power Plant / Crew Boat
Brief summary of sea service for period preceding last five years:
Details of any additional qualifications/special courses/naval service etc.:
Details of any technical groups/associations or professional guilds to which you belong:
Summary of experience ashore: please give details:
What nationalities of crews have you sailed with?
Have you ever been attached to a vessel during:
Major conversion:
New construction: / Fire/Explosion:
Towed or Towing another vessel: / Rescue/Man over board:
Grounding: / Abandon Ship:
experience ashore
Designation / From / To / Company / Nature of duties / G. Salary / Reason for leaving
Details of any additional qualifications/special courses/naval service etc:
medical information
Company Medical Date: / Valid upto:
Port Health Medical Date: / Valid upto:
If ever failed company medical [Yes/No]: / Date:
Drug and Alcohol Test at: / Date:
Date of last medical examination:
vaccinations
Cholera / Date / Expiry / Small Pox / Date / Expiry
Yellow Fever / Date / Expiry / Typhoid / Date / Expiry
Hepatitis 'A' / Date / Expiry
To the best of your knowledge, are you in every way medically fit for sea service? / Yes / No
The following photocopies of documents are also required: / Confirm
1. / Watchkeeping Certificates or Certificates of Service from previous ships. / Yes / No
2. / References from previous employers. / Yes / No
3. / Certificates from School/College/Nautical/Engineering/Trade Institutions. / Yes / No
Please mention alongside total number of photocopies attached.
Any other useful and relevant information you wish to add about yourself and career:
REFERENCES / AVAILIBILITY
May we approach your PRESENT employer for a reference? / Yes / No
May we approach your PAST employers for a reference? / Yes / No
Have you ever had to leave a Company other than voluntarily? / Yes / No
Are you at present serving under Contract? / Yes / No
What period of notice does your present employers require?
What notice do you require to attend an interview?
What date are you available for sea service?
REASONS FOR APPLICATION
State why you wish to leave your
present employment.
UNION MEMBERSHIP
Name of Union / Association
Membership Number
Position Held
Affiliation with Other Trade Organisations
BANK DETAILS (For allotments, other payments)
Account Name: / Account Number
Bank Sort Code:
Bank Name & Branch:
Bank Address
An special instructions required with remittance/payment

Page 1

RECORD OF SEA SERVICE (LAST 5 YEARS)

1. Abbreviations to use for Type Vessel

/

1. Abbreviations to use for Type Main Engines

Dry Cargo Vessels / Tankers / Specialized Vessels / Standard Ocean Going Vessels / Small Engines
GCO / General Cargo / CRT / Crude Carrier / CTR / Container Ship / SZR / Sulzer / CAT / Caterpillar Tractor / RUS / Ruston Diesels
GCK / GC with Stulcken Derrick / PRT / Product Carrier / LSH / Lash Ship / MAN / M.A.N. / KVN / Kelvin Diesels / SKA / Skandiaverken
CBI / Combination Carrier / LPG / LPG Carrier / VHC / Vehicles Carrier / BNW / B.& W.-Burmeister & Wain / GEM / General Motors / KOC / Kockums
BLK / Bulker / LNG / LNG Carrier / ROR / Roll on - Roll off / MNB / M.A.N. / B.& W. / APH / Alpha Diesel / DAE / Daewoo
ORC / Ore Carrier / CHT / Chemical Carrier / PSG / Passenger Vessel / DOX / Doxford / RNH / Ruston & Hornsby / YMZ / Yamanishi Zosen
CEM / Cement Carrier / OBO / Oil / Bulk / Ore / FER / Ferry / GOT / Gotaverken / RRC / Rolls Royce / YMR / Yanmar - Amagasaki
BTN / Bitumen Carrier / BKR / Bunker Supplier / FRO / Ferry / Ro-Ro / HNW / Harland & Wolff / DBZ / Dailmer Benz / DAI / Daihatsu
SUL / Self un-loader / NHZ / Non-hazardous / REF / Refrigerated Cargo / PLK / Pielstick / DTZ / Deutz / HNK / Hanshin Nainenk Kogyo
COL / Collier / LVC / Livestock Carrier / FIA / Fiat / LBN / Lister Blackstone / NIG / Nigata
PSC / Passenger-cum-Cargo / TBC / Timber Carrier / MIR / Mirrless Blackstone / PAX / Paxman Diesels / TAK / Takamatsu
STW / Stork Werkspoor / KRP / Krupp MaK Machinenbrau / KUB / Kubota
Service Vessels / AKA / Akasaka Diesels / BRN / A.G. Bergens / MAT / Matsui Nigata
TUG / Tug / HOP / Hopper / LAN / Landing Craft / STT / Steam Turbine / WAR / Wartsila / Nohab / MAE / Matsue
SAL / Salvage Ship / UTI / Utility Vessel / TRG / Training Ship / GST / Gas Turbine
DRG / Dredger / SUP / Supply Ship / FSH / Fishing Vessel / TBE / Turbo Electric
RES / Research Vessel / CAB / Cable Laying Vessel / FAC / Factory Ship
Other Type not listed to specify
*
Other Type not listed to specify / For UMS engines vessel, abbreviations to be pre-fixed with an asterisk
If combination of 2 types, write both abbreviations with hyphen in between / ‘c’ / For Controllable Pitch Propeller, abbreviations to be pre-fixed with / ‘c’
1
FROM / 2
TO / 3
RANK / 4
SHIP’S NAME / 5
COMPANY / 6
FLAG / 7
TYPE 1. / 8
DWT / 9
ENGINE 2. / 10
B-SHP/KW

Use additional sheets, if required:

Page 1

For Official use only:

INTERVIEW CRITERIA & RECORD

NAME / CDC NO. / DATE / RANK / DATE
Yes / No

PRE INTERVIEW CHECKS

1. Application form filled in and submitted

FAID / AFF / PS / SSL / GMDSS
Y / N / Y / N / Y / N / Y / N / Y / N

(a)The officer meets STCW requirements or short course

Yes / No

1. Original of all certificates listed

On application form sighted. If any

missing then advise details of deficiency.

3 / Travel documents valid until
4 / Any restriction on Travel Document

5. If checked against circulation list of officers not suitable

Yes / No

for re-employment

PAST SERVICE RECORD / HISTORY

1. Reason for seeking employment with Terra-Marine

First Employment / Promotional Reasons / Higher Wages
Differences with previous employer / Redundancy from previous employer

other, specify

1. If ever involved in

Collision / Grounding / Fire / Abandonment
Yes / No / Yes / No / Yes / No / Yes / No

If yes, details

1. If ever deported from any country

If yes, why

1. If ever criminally prosecuted

If yes, details

1. If ever signed of on medical grounds

no / once / 1-3 times / More than 3 times
approx. total no. of days incapacitated

1. Any objection to references from previous employers

Yes / No

[

INTERVIEW

1. / Appearance and general demeanour :
2. / Personality
3. / Communication skill
4. / Attitude to profession as judged by Interview
5. / Knowledge of duties and responsibilities of the rank applied for
6. / Assessment of professional knowledge as assessed by Interviewer:
Yes / No
ASSESSMENT
1. / Officer deemed fit for employment
2. / In what rank
3. / Suitable for assignment to types of vessels
(based on previous service and qualification)
4. / Suitable assignment on vessels with types of main engines
(for engineers on) (based on previous experience)
5. / Reference sought from:
1. / Mr. / of
2. / Mr. / of
3. / Mr. / of
Date of approval from principals to employ:
Officer Offered Employment as
on
Signed
(To be signed by each interview, if more
Than one person on interview panel)

Page 1