SEAFARER’S APPLICATION FORM

船员申请表

This application form serves to provide with all information of the Applicant and will be treated as personal record should the Applicant be
employed. 此表用于填写申请人的个人信息，所填写的内容作为个人纪录登记入库。
Applicant is required to complete all parts in BLOCK CAPITALS. Copies of all certificates, Seaman's book, passport and appraisal from the
previous companies (if any) are to be attached.申请人需要用大写字母填写此表并且提供所有证书扫描件和由上任公司签发的在船评估表。
Applicant must be at least 18 years of age for any position applied. 所有申请人的年龄必须大于（包括）18 岁。

POSITION APPLIED FOR： Date:

申请职务: 日期：

PERSONAL DETAILS 个人信息

Surname 姓 Middle Name Last Name 名 Nationality 国籍

Date of Birth 出生日期 Place of Birth 出生地 Religion 宗教 Age 年龄

Height/Weight Safety Shoe Size Overall Size Marital Status Affix

身高/体重 安全鞋尺码 工作服尺码 婚姻状况 Recent
Colour
Photo
Passport Number Issuing Authority Date of Issue Date of Expiry 粘贴近期照片
护照号 签发机关 签发日期 过期日期

Seaman’s Book Number Issuing Authority Date of Issue Date of Expiry COC Grade
海员证号码 签发机关 签发日期 过期日期 适任证书级别

Mobile Phone Number House Telephone Number Email Address & Skype ID (if Hometown Airport
手机号码 家庭电话 available) 邮箱地址 / 网络电话(SKYPE) 临近机场

Last Salary 上次任职薪水 Readiness 准备就绪日期

Permanent Address 永久地址

HIGHEST ACADEMIC QUALIFICATION 教育信息

Name of University/College Qualifications School period Education Qualification
毕业院校名称 就读专业 (MM/YY-MM/YY) 就读时间 学历

NEXT-OF-KIN 第一联系人
Name 姓名 Relationship 关系 Contact Number 联系方式

Address (if different from the above) 地址（如与上述不同）

Officer Certification (STCW) Certificate Number Issuing Authority Date of Issue Date of Expiry

Form SMS 01 Rev 03/ 15 August 2014 Page 1

 高级船员证书 证书号码 签发机关 签发日期 过期日期

Rating Certification (STCW) Certificate Number Issuing Authority Date of Issue Date of Expiry
普通船员证书 证书号码 签发机关 签发日期 过期日期

Training Certification (STCW) Certificate Number Issuing Authority Date of Issue Date of Expiry
培训合格证 证书号码 签发机关 签发日期 过期日期
Basic Training (VI/1)
基本安全
Proficiency in Survival Craft and
rescue boat(VI/2)
精通救生艇筏
Advanced Fire Fighting(VI/3)
高级消防
Medical First Aid (VI/4-1)
精通急救
Medical Care (VI/4-2)
船上医护
Ship’s Security Officer (VI/5)
船舶保安员
Security Awareness Training
(VI/6) 保安意识培训
Security Designated Duties (VI/6)
负有指定保安职责船员培训
Basic Oil/Chemical Tanker (V/1-1)
油船和化学品货物操作基本培训
Advanced Oil Tanker Cargo
Operations (V/1-2)
油船货物操作高级培训
Advanced Chemical Tanker Cargo
Operations (V/1-2)
化学品船货物操作高级培训
Basic LPG Tanker (V/1-1)
液化气船货物操作基本培训
Advanced LPG Tanker Cargo
Operations (V/1-2)
液化气船货物操作高级培训
Bridge Resource Management
驾驶台资源管理
Ship handling Course
船舶操纵培训
ECDIS
电子海图
Bridge/Engine Team Management
驾驶台/机舱团队管理
MEDICAL AND VACCINATION Certificate Number Issuing Authority Date of Issue Date of Expiry
体检和疫苗 证书号码 签发机关 签发日期 过期日期
Medical Certificate(ILO/MLC)
体检证书
Yellow Fever
黄热
Cholera Vaccination
霍乱

Form SMS 01 Rev 03/ 15 August 2014 Page 2

 SEA SERVICE 海上资历
Type/
Model
Cargo
Name of KW Trading Month
Company Type GT Rank From To
Vessel 主机品 Area s
公司 货物类 总吨 职务 从 至
船名 牌/型 航区 月数
型
号 &马
力

To list Sea Service Period from Junior Officer (for Officer) and lowest Rank (for Rating) onward.
对高级船员的资历，请从三副三管轮开始的所有海上服务资历列起；对普通船员的资历，从最低职位海上资历列起。

Form SMS 01 Rev 03/ 15 August 2014 Page 3

DETAILS OF TANKER TRADE * delete whichever is not applicable
Chemical Tanker Experience
Oil Tanker Experience 油轮经验 YES / NO* YES / NO*
化学品船经验
USCG (TVEL) Inspection Ship To Ship Experience
YES / NO* YES / NO*
美国海岸检查经验 船靠船经验
PSC Inspection Experience Vetting Inspection Experience
YES / NO* YES / NO*
港口国检查经验 油公司检查经验
Types of Cargo Carried Experience Oil Products Name
运输货物类型/种类 成品油名字
Types of Cargo Carried Experience Chemical Products
运输货物类型/种类 Name 化学品名字
Dry Dock Experience (indicate shipyard)
船坞修船经验（包括船厂信息）
Cargo Pumps Experience
Framo, Deepwell, Centrifugal, Screw , Steam Turbine, Marflex(electrical driven) *
货泵经验
Tank’s Coating Type Experience
Epoxy 环氧树脂, Zinc Silicate 硅酸锌, Stainless Steel 不锈钢, Marlin line 马琳线 *
货仓涂层类型经验

Total Sea Service on Oil Tankers Total Sea Service on Chemical Tankers Months 月
Months 月
所有油轮海上经验 所有化学品船海上经验

Total Sea Service on All Type Tankers Months 月 Total Sea Service in Present Rank Months 月
所有各种类型液货船海上经验 所有现在职位海上经验
Experience with
Total Sea Service Months 月 Nationalities 和
所有海上经验 外国船员一起工
作经验
English Proficiency 英语精通程度
Good 好 , Fair 还好 , Average 中, Poor 差 *

APPLICANT’S DECLARATION 申请人声明

Medical History / Background
Yes/No If yes, please provide details
医疗历史记录/背景调查

Do you have history of illness such as tuberculosis, high blood pressure,

mental illness etc…?
你是否有患有某些疾病，如肺结核，高血压，精神病等？

Do you have physical disability?

你是否患有心理疾病？

Have you ever been hospitalised, operated or currently undergoing any

medical treatment?
你是否曾经有住院，动手术的经历或者现在正在进行药物治疗？
Have you had premature termination of employment agreement?
你是否曾经有未完成合同下船的经历？
Have you been dismissed or logged for misconduct?
你是否曾经有因为行为不当而被解雇的经历？
Have you been refused entry by any country?
你是否曾经有被拒绝进入某个国家
Have you ever been charged in court for any offence?
你是否曾经有接受到指控？
Do you have alcohol drinking habit?
你是否有饮酒的习惯？

I confirm that the information given by me herein is true and correct. I also understand that any falsification or misrepresentation in my
personnel records can result in my immediate dismissal and may be subject to legal action if I am employed by the Company. I do agree
to submit myself to a thorough medical examination, which I must successfully pass as one of the conditions for being accepted for
employment.

我确认我所提供的信息均是正确且真实的。我理解任何伪造的个人信息将会导致公司立即解雇我或者采取法律程序。我本人将接受
并通过身体检查，并且同意将其作为被公司雇用的条件之一。

Date: Signature:
日期： 签名：

Form SMS 01 Rev 03/ 15 August 2014 Page 4

FOR INTERNAL USE ONLY

INITIAL INTERVIEW SIGHTED CHECKED Prepared by:

Original Experience confirmed by
Licenses/Passport/CDC interview
STCW and Training Details confirmed by
Certificates Interview.
References Checked Company Name Remarks

GRADING ATTITUDE EXPERIENCE PERSONALITY ENGLISH KNOWLEDGE OVERALL

COMMUNICATION ASSESMENT
Excellent            
Good            
Satisfactory            
Poor            

Interviewed by:   Date:  

Additional Comments:

Form SMS 01 Rev 03/ 15 August 2014 Page 5