CEYLON SHIPPING CORPORATION LTD.

REVISION
HEALTH SAFETY SECURITY ENVIRONMENTAL NO : 0
DATE 07.01.16
MANAGEMENT SYSTEM
ISSUED : DPA
SEA STAFF APPLICATION FORM CCF 015 APPROVED : TM

Post Applied For: ____________________________ Date: ___________________

Section 1: PERSONAL PARTICULARS
Name:
Permanent Address:

Present Contact Address:

Telephone no.: Fax no.: e-mail:

Date/Place of Birth: Nationality:
Marital Status: Name of Spouse:
Nos. of Children (mention age)
Next of Kin & Relationship:
Address & Tel. no.:

Section 2: CERIFICATES ( Photocopies to be provided)

Passport No.: Date/Place of Issue: Date of expiry:
CDC No. Date/Place of Issue: Date of expiry:
Competency Cert. Grade/Class: Date/Place of Issue:
Cert. No. Date of Revalidation: STCW Endorsement: YES/NO
Medical Cert. No. Date/Place of Issue: Date of expiry:
GMDSS Cert. No. Date/Place of Issue: Date of expiry:
Int. Audit Cert. No. Date/Place of Issue: Date of expiry:
Computer Literacy: YES/NO If yes, give details of training:
Any other Qualifications:
Any other Qualifications:
Section 3: ACADEMIC QUALIFICATION -SCHOOL/COLLEGE
Grade/Div.: Year:
Grade/Div.: Year:
Section 4: APPRENTICESHIP/TRAINING INSTITUTE
From: To:
From: To:
Section 5: RECORD OF PREVIOUS EMPLOYMENT
Vessel Name Type of DWT Type of BHP Rank Service Period
Vessel M/E From To

Section 6: Summery of Sea Services:

Master/ Chief Engineer: Ch. Off./2nd Engr: 2nd Off /3rd Engr.:
rd th
3 Off /4 Engr.: Dk.Cadet/Eng.Cadet: El. Engr.:
I do hereby certify that the above information is to the best of my knowledge correct. Further I understand that a
strict medical examination is a condition precedent to select for appointment and I express my willingness to be
so examined if required.

____________________
Signature of Applicant