OCEANGOLD MANAGEMENT SYSTEM / OC-01

SEAFARER APPLICATION FORM

PERSONAL DETAILS
FAMILY NAME / FATHER’S NAME
FIRST NAME / MARRIED OR SINGLE
RANK / No OF CHILDREN
DATE / PLACE OF BIRTH / OVERALL / SAFETY SHOE SIZE
NATIONALITY / RELIGION / HEIGHT / WEIGHT
PERMANENT ADDRESS / HOME TOWN AIRPORT
CITY / READINESS
TEMPORARY ADDRESS / NEXT OF KIN
CITY / ADDRESS
PHONE No. MOB No. / CITY
EMAIL / Skype: / PHONE No.
SALARY REQUIRED / MOB No.
MANNING AGENT / Ε-mail / PHONE No.
Academic Background
Name of Institution / Country / From / To / Qualification Obtained / Grade / Percentage
DOCUMENTS
SB NR.: / ISSUED DATE : / PLACE ISSUED : / EXP.DATE :
PASSPORT No.: / ISSUED DATE : / PLACE ISSUED : / EXP.DATE :
USA VISA / ISSUED DATE : / PLACE ISSUED : / EXP.DATE :
VACCINATION BOOK / ISSUED DATE : / PLACE ISSUED / EXP.DATE :
FOREIGN LANGUAGES / ENGLISH / OTHER / OTHER
TOTAL TEST SCORE : / INTERVIEW SCORE :
ANY PREVIOUS ILLNESS / YES / NO / IF YES PLEASE STATE
CERTIFICATES & ENDORSEMENTS
NATIONAL C.O.C. / NR / ISSUED DATE / EXP.DATE
LIBERIA ENDORSEMENT: / NR / ISSUED DATE / EXP.DATE
LIBERIA SEAMAN’S BOOK / NR / ISSUED DATE / EXP.DATE
GIBRALTAR ENDORSEMEN : / NR / ISSUED DATE / EXP.DATE
MINIMUM STCW CERTIFICATES
BASIC SAFETY TRAINING CERT / NR / ISSUED DATE / EXP.DATE
PSCRB / NR / ISSUED DATE / EXP.DATE
ADVANCED FIRE FIGHTING CERT / NR / ISSUED DATE / EXP.DATE
MEDICAL FIRST AID / NR / ISSUED DATE / EXP.DATE
STCW COURSES
GMDSS/G.O. CERT. / NR / ISSUED DATE / EXP.DATE
ARPA / NR / ISSUED DATE / EXP.DATE
ECDIS GENERIC CERT / NR / ISSUED DATE / EXP.DATE
MEDICAL CARE / NR / ISSUED DATE / EXP.DATE
BASIC TRAINING FOR OIL AND CHEMICAL TANKER / NR / ISSUED DATE / EXP.DATE
ADVANCED TRAINING FOR OIL TANKER / NR / ISSUED DATE / EXP.DATE
ADVANCED TRAINING FOR CHEMICAL TANKER / NR / ISSUED DATE / EXP.DATE
SHIP SECURITY OFFICER / NR / ISSUED DATE / EXP.DATE
SHIP DESIGNATED SECURITY DUTIES / NR / ISSUED DATE / EXP.DATE
SHIP SECURITY AWARENESS / NR / ISSUED DATE / EXP.DATE
BRIDGE TEAM AND RESOURCE MANAGEMENT / NR / ISSUED DATE / EXP.DATE
ENGINE RESOURCE MANAGEMENT / NR / ISSUED DATE / EXP.DATE
OTHER COURSES
ECDIS TYPE SPECIFIC / NR / TYPE: / ISSUED DATE / EXP.DATE
SHIP’S HANDLING AND MANOEUVERING CERT / NR / ISSUED DATE / EXP.DATE
SAFETY OFFICER / NR / ISSUED DATE / EXP.DATE
CARGO BALLAST HANDLING / NR / ISSUED DATE / EXP.DATE
MAN B&W ELECTRONIC MAIN ENGINES / NR / ISSUED DATE / EXP.DATE
RISK ASSESSMENT / NR / ISSUED DATE / EXP.DATE
INCIDENT INVESTIGATION / NR / ISSUED DATE / EXP.DATE
MARPOL I / II / III / IV / V /VI / NR / ISSUED DATE / EXP.DATE
OIL WATER SEPARATOR / NR / ISSUED DATE / EXP.DATE
WELDING / NR / ISSUED DATE / EXP.DATE
FRAMO / NR / ISSUED DATE / EXP.DATE
CATERING MANAGEMENT / NR / ISSUED DATE / EXP.DATE
FRAMO / NR / ISSUED DATE / EXP.DATE
COMPANY SMS FAMILIARIZATION / NR / ISSUED DATE / EXP.DATE
Practical Experience : Have you experience of the following (Please signify thus 'X')
New Building / Main Engine Automation / Planned Maintenance System
a)  Kongsberg / [ ] / Computerized (specify)
b)  Wapco / [ ] / a)  DANAOS / [ ]
c)  Other: ______/ [ ] / b)  AMOS / [ ]
c)  Other: ______/ [ ]
Cargo Pump Type / Attendances During:
a)  Centrifugal Steam Driven Pumps / [ ] / a) Major Repairs / [ ]
b)  Engine Driven Cargo Pumps / [ ] / b) Major Fire / [ ]
c)  FRAMO Pumps / [ ] / c) Collision / [ ]
d)  SCREW Pumps / [ ] / d) Pollution Incident / [ ]
e)  Dry-docking / [ ]
Boilers / Aux. Engines
a)  Aalborg / [ ] / a) Yanmar / [ ]
b)  Kangrim / [ ] / b) Daihatsu / [ ]
c)  D-Type / [ ] / c) Man B & W / [ ]
d)  Sunrod Type / [ ] / d) Himsen / [ ]
Main Engines
a)  MAN B&W MC engines
b)  MAN B&W ME engines (Electronic) / [ ]
[ ]
1.Trading Area of the last 3 (three) Contracts with Tankers
2. If USA / Last call in USA:
3.Vetting Inspection Experience
(a) Oil Majors Company Name:
(b) Ports of Inspection:
(c) Inspectors Nationality:
4.Engine Room Organization / UMS Operation or Fully Manned :
5.Chemical Tankers Experience - IGS Type: Flue Gas or IGS Generator:
6. Centrifugal Pumps Experiences:
Enumerate the different Nationalities you have sailed :
Officers :
Ratings :
Reason for application : State why you wish to leave your present employment :

PREVIOUS SEA SERVICE ( FOR MASTER 10 YEARS, OTHERS 5 YEARS)

VSL TYPE Tankers / VESSEL’S NAME / DATE OF BUILT / FLAG / OWNERS
MANAGERS / RANK / D.W. BHP / ENGINE TYPE / FROM / TO / REASON FOR SIGN OFF
Officers with experience on Product/Chemical tankers, please state Cargoes carried:

Here below to be endorsed references from previously Employers,

providing Name of Person, contact details & Score.

Company: / Referee’s Name: / Tel. No.: / e-mail:
Comments / Score:
Company: / Referee’s Name: / Tel. No.: / e-mail:
Comments / Score:
Company: / Referee’s Name: / Tel. No.: / e-mail:
Comments / Score:

DATE ______CHECKED BY AGENTS______

PLACE______SIGNATURE ______

§  Employment Criteria to be checked in Accordance with Procedure CP05, Appendix I. ¨

§  Certificates and Endorsements to be checked in accordance with Form OC-09 per Rank. ¨

§  Total Test Score for Professional Knowledge on the Skills of Positions Applied.

§  Interview Form to be attached for every newly proposed or promoted seafarer. Score :

§  Copy of Seaman’s book to be attached

FOR OFFICE USE ONLY

Accepted for: M/T ……………………… / Date Proposed by Crew/Manning :
General Manager : / Date Interviewed by G.M.
Marine/Operations Manager : / Date Interviewed by OPS/DPT
Technical Manager : / Date Interviewed by TECH/DPT
Crew Manager : / Date Interviewed by CREW DPT or MANAGER
Comments by Crew Department:
Seafarer Application Form / OC-01 / Rev. No.05

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