Form Ref.

: SPSEI-WI01-OPR01-01
Rev.: 01/11 November 2011

2x2
Photo UKAS
APPLICATION FORM FOR NEW APPLICANT
QUALITY
MANAGEMENT
ISO 9001:2008 Reg. No 059
NOTE: WRITE ALL ENTRIES IN CAPITAL LETTERS
CERTIFICATE NUMBER AJA09/13489

Date:

Position Applied for: 1st Choice 2nd Choice

GENERAL INFORMATION
Name:
(Surname) (Name) (Middle)
Address in Metro Manila: Tel:
Address in the Province: Tel:
Birth Date: Birth Place: Age: Religion:
Height: Civil Status: Weight: Complexion:

Name of Spouse: Number of Children:

Date of Birth: Place of Birth:
Name of Beneficiary/Address:
Father’s Name: Mother’s Name:
Name of nearest relative: Address:
Relation to the above: Tel:

EDUCATIONAL ATTAINMENT
Name of School Degree Obtained Inclusive Dates
Secondary/College
Basic Seaman’s Course
Nautical/Marine Graduate
Vocational Training
Language Spoken

DOCUMENTS
SIRB Number: Date Issued: Expiration Date:
Passport Number: Date Issued: Expiration Date:
SRC Number: Date Issued: Expiration Date:
SOLAS Certificates: Authenticated? Yes No MARINA Endorsement: Yes No Expiration Date:
Philippine License Position: Number: Date Issued: Expiration Date:
Liberian License Position: Number: Date Issued: Expiration Date:
Liberian Seaman Book Yes No Date Issued: Expiration Date:
Panama Seaman Book Yes No Date Issued: Expiration Date:
USA Visa Yes No Valid Until:
SSS Number: Pag-ibig Number: TIN:

PLEASE ANSWER
1. Are you willing to accept assignment in any part of the world?
2. Are you willing to accept any assignment in warzone areas?
3. Of what Seaman’s Union are you a member?
4. Have you been involved in I.T.F. cases?
5. Have you ever been discharged for a cause?
6. Do you have a pending or finished case with the POEA?
7. Do you have any kind of sickness at present or in the past?
8. Were you recommended for the job by someone? If yes, please affix his name and his position as well as the last vessel he was connected with

FOR OFFICE USE ONLY

EX VG GOOD AVERAGE POOR
Appearance
Behavior
Intelligence
English Language (Marine)
Technical Knowledge
Personality
Date/Time of Interview:
Interviewed by:
For M / :
SEA SERVICE
Please register your latest Six (6) employments, filling up all spaces provided. Your latest service to be registered first and others to follow:

Foreign Principal/Nationality 6. 5. 4.
Philippine Agency
Ship’s Name
Ship’s Type (BC, C, Tkr, Cont. etc.)
Ship’s Flag
GRT
Year Built
Position
Period (from-to)
Salary
Reason signed-off

(Only for Engine Crew/Electricians)

Engine Type/HP
Auxiliary engine
Type of gear on deck
Lathe Machine exp/nce (YES/NO)
Pipe fitting exp/nce (YES/NO)
Welding experience (YES/NO)

Foreign Principal/Nationality 3. 2. 1.
Philippine Agency
Ship’s Name
Ship’s Type (BC, C, Tkr, Cont. etc.)
Ship’s Flag
GRT
Year Built
Position
Period (from-to)
Salary
-
Reason signed-off

(Only for Engine Crew/Electricians)

Engine Type/HP
Auxiliary engine
Type of gear on deck
Lathe Machine exp/nce (YES/NO)
Pipe fitting exp/nce (YES/NO)
Welding experience (YES/NO)

Total actual sea service: Total actual sea service in the position you apply:
Salary received in last vessel: Basic O/T:
Recommended By:

Reference: 1,

I HEREBY CERTIFY that the foregoing information is true and correct. I also certify that I have not paid nor promised to pay any monetary
consideration other than allowed by law. In case any of the foregoing information is not true or is misguiding, SEA POWER has the right to reject my
application and be used against me.

Signature