COMPANY WORK FORM

Form No.
Issue A Date
Authorised By

SEAFARERS APPLICATION FORM

DATE AVAILABLE:
POSITION APPLIED FOR:
FULL NAME:
SURNAME:
FIRST NAME:
MIDDLE NAME(S)
DATE OF BIRTH

WEIGHT

F.6.2
01/11/06
MD

ATTACH
PHOTO
HERE

PERSONAL DETAILS

PLACE OF BIRTH

NATIONALITY

HEIGHT

HAIR COLOUR

MARITAL STATUS

SPOUSES NAME

FATHERS NAME

MOTHERS NAME

EYE
COLOUR
No. of
Children
NEXT OF
KIN

HOME ADDRESS
(PERMANENT)
OTHER ADDRESS
E-MAIL:

TEL. No.
HOMEPORT:

Mob No.

LICENCES / DOCUMENTS HELD

ITEM

No.

I S S U E D
PLACE

DATE
NATIONAL LICENCE
STCW ENDORSEMENT
MARSHALLS ISL. ENDORSEMENT
LIBERIAN ENDORSEMENT
OTHER LICENCE
PASSPORT
NATIONAL SEAMANS BOOK/CDC
OTHER SEAMANS BOOK / CDC
U.S.VISA
YELLOW FEVER VACCINATION
P.R.C. No. (Filipino Crew only)
National data base of seafarers INDOS
Certificate No. (Indian personnel only)

No.

ISSUED

EXPIRING
DATE

BY

CERTIFICATES HELD

BASIC SAFETY TRAINING (*IF ONE CERTIFICATE)

PERSONAL SAFETY & SOCIAL RESPONSIBILITIES*
PERSONAL SURVIVAL*
SURVIVAL CRAFT HANDLING*
FIRST AID AT SEA (ELEMENTARY LEVEL)*
PROFICIENCY IN SURV.CRAFT/ RESCUE BOAT (PSCRB)
ADVANCED / SHORE-BASED FIREFIGHTING
PETROLEUM TKR SAFETY BASIC/ GEN OIL TKR FAM.
MEDICAL FIRST AID
SHIP MASTERS MEDICARE/ADVANCED MEFA
PETROLEUM TKR SAFETY ADVANCED/SPECIALISED
COW / IGS
DANGEROUS CARGO ENDORSEMENT - OIL
CHEMICAL TANKER SAFETY
LIQUIFIED GAS FAMILIARISATION
LIQUIFIED GAS SPECIALISED/ADVANCED COURSE
DANGEROUS CARGO ENDORSEMENT - LIQUIFIED GAS
LICOS (FOR LIQUIFIED GAS PLS SPECIFY)
LIQUIFIED GAS-SPECIFIC FIRE FIGHTING PLS SPECIFY
SIGTTO
STCW ENDORSEMENT
ARPA
R.O.C. / RANSCO / RADAR SIMULATOR
SATCOM

EXPIRING

\\\

APPLICANTS NAME: _________________________________________________________

Rev. 3 dated 30/09/15
1 of 3

TEL. No.

SKYPE:

ITEM

GRADE

ISSUED BY

COMPANY WORK FORM

Form No.
Issue A Date
Authorised By

SEAFARERS APPLICATION FORM

F.6.2
01/11/06
MD

CERTIFICATES HELD (CONTINUED)

ITEM
GOC / GMDSS

No.

ISSUED

EXPIRING

ISSUED BY

ECDIS
SHIP MANOEUVERING/SHIP HANDLING SIMULATOR
SHIP SECURITY OFFICER
ISPS FAMILIARISATION
SHIPBOARD SAFETY OFFICER
ENGINE ROOM SIMULATOR
ENGINE ROOM RESOURCES MANAGEMENT
HUMAN RELATIONS
QUALITY AND SAFETY MANAGEMENT
RISK ASSESSMENT / RISK MANAGEMENT
MARINE ACCIDENT/INCIDENT INVESTIGATION
MANAGEMENT OF CHANGE
ENVIRONMENTAL COURSE / ISO 14001
MLC/LSC MARITIME LEADERSHIP COURSE
MARPOL I
MARPOL II
MARPOL VI
MARITIME ENGLISH
MLC 2006
BRIDGE TEAM MANAGEMENT
BRIDGE RESOURCES MANAGEMENT

RECORD OF PREVIOUS SERVICE (VERIFIED AGAINST SEAMANS BOOK ENTRIES)

COMPANY

VESSELS
NAME

TYPE/
BUILT

M/ENGS BHP/
TYPE

Rev. 3 dated 30/09/15

2 of 3

DWT

UMS
( Y-N)

MONTHS

RANK

FROM

TO

COMPANY WORK FORM

Form No.
Issue A Date
Authorised By

SEAFARERS APPLICATION FORM

F.6.2
01/11/06
MD

APPLICANTS NAME: ___________________________________________________________________

ACTUAL TIME SERVED IN MONTHS

LNG

RANK
MASTER OR CH. ENG.
C/OFF OR 1A/E
2/OFF OR 2A/E
3/OFF OR 3A/E
GAS/CARGO ENGINEER
CADET/JR.ENG
ETO / ELEC (PLS STATE)
PMN / FITTER
OTHER RANK

CRUDE OIL
TANKER

LPG

OBO / CHEM. /
PRODUCT
TANKER

BULK
CARRIER/
OTHER

ALLOTMENT DETAILS
SURNAME
NAME
MIDDLE NAME
DATE OF BIRTH
RELATIONSHIP
ADDRESS
NAME OF BANK
ACCOUNT No.
SSS No. (Filipino crew only)
TIN No. (Filipino crew only)

WIFE & CHILDRENS NAME S

DOB

POB

PASSPORT NO.

DATE OF

ISSUE

How long did you stay at your previous company?

Wages on last vessel?
Trade route of vessels?
Who referred you to the company?
Any relatives with the company?
If yes, who?

ANY OTHER INFORMATION ABOUT YOURSELF:

DATE :

UNION MEMBERSHIP NO.:

DOE:

ALL APPLICANTS
DATE APPLICATION FILLED OUT
SIGNATURE OF APPLICANT
FULL NAME IN BLOCK CAPITALS

Rev. 3 dated 30/09/15

3 of 3

ISSUED AT

EXPIRY