Officer Application Form Ref.

No
(for official use)
ver 004R / 10.2016
Please fill and send to

LOCATION YOU ARE APPLYING FROM:

Country (please specify if other)

APPLICATION FOR POSITION AS: PLEASE

PASTE
RECENT
AVAILABILITY DATE : PHOTO
dd-mmm-yyyy

Name:
first name middle initials last name / surname

Nationality:

Full address :

Country : Postal Code :

E-mail id :

Home/ Alternate telephone no: Mobile phone :

Domestic Airport : International Airport :

Marital Status :

Full Name of Next of Kin : Relationship :

Address of Next of Kin :

Contact Number of Next of Kin : Email of Next of Kin :

Person to Contact In Case Of Emergency or Accident

Name :

Relationship with Person :

Address :

Contact Number :

Do you hold a valid passport for at least 1 year? Yes No Issuing authority

Do you hold a valid Seaman book for at least 1 year? Yes No Issuing authority

Do you have Yellow Fever vaccination with at least 1 year of validity? Yes No

Do you hold all valid STCW certificates mandatory for the rank applied for? Yes No

If select "No", please list down the STCW certificates that are lacking.

Certificate of Competency (COC)

Grade Issuing Authority Number Date of Issue Date of Expiry Place of Issue
(dd-mmm-yyyy) (dd-mmm-yyyy)

ver 004/ 10.2016 Page 1 of 4

 Officer Application Form Ref. No
(for official use)

Value-added Courses Done in Last 5 Years

Course Name

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

Employment History (Please Start With Your Latest Sailing Experience On Top Row )
Type of Vessel
Please complete all fields
Voyage
From To Total Type
Company Name of Vessel (Foreign Rank Reefer
(dd-mmm-yyyy) (dd-mmm-yyyy) MM-DD Vessel TEU
Going / GRT TEU BHP UMS Main Engine
Coastal) Type (For E/E
only)

*In Case You Have More Sea Experience, Please Utilise The Additional Seatime Sheet

Date when Promoted to Current Rank :

dd-mmm-yyyy

Notice Period

Upon shortlisting, may we contact your last employer for reference check? Yes No

By ticking the box or signing below, I hereby certify that the above information, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me from being hired
or lead to my dismissal if hired. I authorise the use, retention and distribution of my personal data contained in this application for the purpose of processing my job application.

Date Signature
dd-mmm-yyyy

ver 004/ 10.2016 Page 2 of 4

 Officer Application Form Ref. No
(for official use)

Where did you find out about our recruitment exercise?

Please Check Specify Details
Newspaper

Flyers

Friends / Family members already in this organization

Internet

Others: Please specify

Please fill and send to

ver 004/ 10.2016 Page 3 of 4

 Officer Application Form Ref. No
(for official use)

Employment History (Please Start With Your Latest Sailing Experience On Top Row )
Type of Vessel
Voyage Please complete all fields
From To Total Type
Company Name of Vessel (Foreign Rank Reefer
(dd-mmm-yyyy) (dd-mmm-yyyy) MM-DD Vessel TEU
Going / GRT TEU BHP UMS Main Engine
Coastal) Type (For E/E
only)

ver 004/ 10.2016