APPLICATION / INTERVIEW FORM

I confirm that the personal data provided to The China Navigation Company Pte Ltd (CNCo)/ Swire Pacific Ship Management (SPSM) as set out herein is tru
complete and accurate and undertake to keep CNCo/SPSM informed if any of the personal data provided therein has changed.

I have also read and understood the “Job Applicants Data Protection and Privacy Notice”, a copy of which is published on CNCo’s website at http://swirecnc

I am aware that the said notice sets out, amongst others, the personal data that CNCo/SPSM collects, their legal bases and purposes of processing such data
as the other third parties to whom CNCo/SPSM discloses such data.”

Position Applied for Date:

Please indicate if willing to accept a lower position if not offered job YES NO
applied
Personal Details

Surname : Photo
Name :
Date of birth : Place of birth : Height :
Nationality : Marital Status : Weight :
Passport : Date of Issue : Date of expiry :
US Visa : Date of Issue : Date of expiry :
House Phone : E-Mail :
Mobile Phone : Skype :
Home Address :

Next of Kin Details

NOK Name :
House Phone : Relationship :
Mobile Phone : E-Mail :
Home Address :
Please attach Sanctions Checklist with this form
Employment History
Rank From Till Sea Time (Mths) Manager/Owner Vessel name Vessel Type Flag DWT
Total Time For Each Rank

Rank Total Time (Yrs) Rank Total Time (Yrs) Rank Total Time (Yrs)
Master C/E ETO

C/O 2/E 2ETO

2/O 3/E T/O

3/O 4/E EL/

CDT
4/O 5/E

D/CDT E/CDT
gement (SPSM) as set out herein is true,
changed.

d on CNCo’s website at http://swirecnco.com/index.php?option=com_content&view=article&id=1516&Itemid=158.

s and purposes of processing such data as well

Photo

GRT Engine Type / HP

al Time (Yrs)
Education
Qualification Name of Maritime College / University From

Licences

Seaman Book : Date of Issue : Date of expiry : Place of Issue :

COC : Date of Issue : Date of expiry : Place of Issue :

Certificates

Certificates of Competency / Proficiency Place of Issue Date of Issue

STCW 2010 COMPLIANCE YES

Certificates Number Date of Issue

Advanced Fire Fighting (A-VI/3)

Basic Safety Training (A-VI/1-4)

Designated Security Duties (A-VI/6-2)

Generic ECDIS (A-II/1 & II/2)

Electronic Navigation Systems (Radar or ARPA, if fitted)

Elementary First Aid (A-VI/1-3)

Fast Rescue Boat (A-VI/2-2)

Fire Prevention & Fire Fighting (A-VI/1-2)

GMDSS (A-VI/2)

Medical Care (A-VI/4-2)

Medical First Aid (A-VI/4-1)

Personal Safety & Social Responsibility (A-VI/1-4)

Personal Survival Techniques (A-VI/1-1)

Proficiency in Survival Craft & Rescue Boats (other than FRB) A-VI/2

Security AwarenessTraining (A-VI/6)

Designated Security Duties(A-VI/6-2)

Ship Security Officer (SSO) (A-VI/5)

Bridge Team Management (BTM)

Bridge Resource Management (BRM)

Engine Room Resource Management (ERM)

ECDIS Type : SPERRY FURUNO JRC Transas

Cargo Type : MPP Bul Logs Cement Cars Heavy Lift

k
Passengers Reefer Steel Others Please Specify :
All Engineers : Dry Docking New Building Other Engineering Projects Please Specify :
English Level : Good / Satisfactory / Poor
 Till

Date of Expiry

NO

Date of Expiry

Ro-Ro
Question :-
1. Do you have a valid medical certificate / Date of last medicals?

2. Are there any other illness, disabilities or defects present, that may require treatment and have not already been disclosed.
If so, please provide full details.

3. Reason for leaving your previous employment

4. If you have not sailed in the last six month prior application, please advise reason

I hereby affirm that all the information provided by me in this form is TRUE and CORRECT to the best

of my knowledge.

Seafarer's signature:                                                      

FOR OFFICIAL USE ONLY

Interview Notes
1. Crewing (if Any)

2. Safety and Training (if Any)

3. Ship Manager /QA Dept. (if Any)

*For Senior Officer / Engineer, please refer to Interview Form

Final Decision by Panel
EMPLOY     //    DO NOT EMPLOY
equire treatment and have not already been disclosed.

dvise reason

TRUE and CORRECT to the best

Date :