Ref: / Ship Personnel Management / Pages: / 1/4
Form No. & Title: / (03-01-O) Crew Application Form / Date / 01.08. 12
Date of application:
1. Instructions
1.1 This application form has been designed to provide us with the basic information for easy processing of your application for employment with us. It also serves as our personnel record should you be employed.
1.2 It is essential for you and helpful to the interviewer that the form is neatly, carefully and correctly filled. Please use BLOCK CAPITALS.
1.3 All parts are to be completed and where not applicable, state N.A.
1.4 If space is not sufficient, please attached an addendum.
1.5 All relevant certificates, discharge book, passport, testimonials, references of previous employment, if any to be attached.
2. Position Applied For
2.1 Application for position of:2.2 Source of application: agency personal contact others*.
* Select whichever is applicable
3. Personal Particulars
3.1 Full Name / 3.2 Telephone No.3.3 Address
3.4 Repatriation Port / 3.5 Height
cm / 3.6 Weight
kg / 3.7 Blood Group
3.8 Colour of Eye / 3.9 Boiler Suit Size / 3.10 Shoe Size
US - / 3.11 Religion
3.10 Date of birth / age
/ 3.11 Place of Birth / 3.14 Nationality
<double click>BangladeshiBurmeseChineseIndonesianFilipinoOthers / 3.15 Marital Status
<double click>SingleMarriedDivorced
3.16 Passport No. / 3.17 Date of issue / 3.18 Date of Expiry / 3.19 Place of issue
3.20 Discharge Book No / 3.21 Date of issue / 3.22 Date 6f Expiry / 3.23 Place of Issue
4. Emergency Contact (Immediate Family Members)
Full Name: / Relationship:Address, if different from above: / Telephone:
Family members ( Parents, Kids, Wife/Husband)
Name / D.O.B / Relationship / Occupation
5. Certificate of Competency / Endorsements
5.1 Grade: / 5.2 Grade / 5.3 Certificate no: / 5.4 Date & Place of issue:Certificate of Competency
STCW 95 Endorsement
Tanker Endorsement (Oil/Chemical/Gas)
Certificate Of Equivalence (CEC)
6. STCW Training Certificate
6.1 Certificate: / 6.2 Certificate No. / 6.3 Date of Issue / 6.4 Issuing Authority1. Advanced Oil Tanker Familiarization
1. Advanced Chemical Tanker Familiarization
2. Medical Care onboard / First Aid at
Sea
3. Navigation Control Course
4. Advanced / Basic Fire-fighting
5. GMDSS GOC
6. Proficiency in Survival Craft
& Rescue Boat */ Personnel Survival
Technique
7. Basic Safety Training *
8. Electronic Navigational Course (Radar & ARPA)
9. Tanker Familiarization *
(Oil/Chemical/Gas)
*Deck and Engine Ratings are required to produce these Certificates in their Application
7. Other Training
7.1 Type of training: / 7.2 Certificate No: / 7.3 Period:1. BTM
2. SHIP HANDLING
3. ISM Code
4. SSO & Others
8. General Education
8.1 Please give details of your institution where you have graduated and obtain your COC from.From / To / Level
9. Language Proficiency
9.1 Language (Bad, Average, Good, Excellent) / 9.2 Spoken* / 9.3 Written*English / <double click>AverageGoodExcellentPoor / <double click>AverageGoodExcellentPoor
Mother Tongue: <double click>BahasaBengaliChineseMyanmarTagalogOthers / <double click>AverageGoodExcellentPoor / <double click>AverageGoodExcellentPoor
10. Previous Employment (last 5 years)
10.1Name of
ex-Employer / 10.2
Name of
Vessel / 10.3
Flag of / 10.4
Type / 10.5
Trade+ / 10.6 Rank / 10.7
GRT/ KW++ / 10.8
Period of Service
Vessel / From / To / Months
<double click>Oil onlyIMO2 onlyOil/IMO2CrudeBitumenBunkerOthers / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
<double click>AverageGoodExcellentPoor / <double click>HarbourRegionalWorldwide
11. Bank Details
11.1 Bank Name / 11.2 Bank Address11.3 Account Name / 11.4 Account Number / 11.5 Code Swift
Beneficiary Details
Full Name: / Beneficiary Address:
Nationality:
/ D.O.B: / Place of Birth:
12. Medical History
12.1 Please state with dates of any serious illness, operations or disability:12.2 Do you suffer from any physical impairment? If YES, give details.
13. Criminal Record
13.1 Have you ever been convicted in a court of law in any country? If YES, give details.14. Referral from previous company
Name of company:Address:
Point of referral:
15. Declaration to be signed by the Applicant
14.1 I hereby declare that the information contained in this form is true and correct to the best of my knowledge and belief, and that I have withheld nothing that would affect this application. I also understand that if employed, my services may be terminated if any of the information given above is found to be false.14.2 I understand that a strict medical examination is a condition precedent to selection for appointment and I express my willingness to be so examined and to furnish the consulting physician with full details of my previous medical history.
Signature of Applicant: ______Date:
+ For Home Trade state HT, for Foreign Going state FG, for Highsea Bunkering state HB, for Special Limit state SL
++ For Deck state GRT, for Engine state kW/BHP
SQST/ISM/SMSM/Forms 03