L3-CREW-FRM-56 CREW APPLICATION REV 0

Company NIMBUS MARITIME SERVICE PVT LTD

Date

POSITION APPLIED

Date of Availability

Nearest Airport

PERSONAL PARTICULARS
Name Rank
Date Of Birth Place Of Birth
Marital Status Nationality
Religion Blood Group
E-mail PPE Size
Home Tel. No Mobile No.
Height (cm) Weight (kgs)

Home Address
Postal Code:
TRAVEL DOCUMENTS NUMBER DATE OF ISSUE DATE OF EXPIRY PLACE OF ISSUE

CERTIFICATE OF COMPETENCY CAPACITY DATE OF ISSUE DATE OF EXPIRY

Certificate of Competency (Home Country)
Certificate of Endorsement (Home Country)
General Operator Certificate (GOC) (Home Country)
FLAGSTATE DOCUMENTS CAPACITY DATE OF ISSUE DATE OF EXPIRY
Singapore /Panama/ Malaysia / indonesia- COE / COR
Singapore /Panama/ Malaysian / Indonesia - GOC / COR
Singapore /Panama/ Malaysian / indonesia - SIRB / SID

MEDICAL CERTIFICATE CLINIC DATE OF ISSUE DATE OF EXPIRY

Petronas / BSP / PANAMA
Others :
NOS. TRAINING CERTIFICATES DATE OF ISSUE DATE OF EXPIRY
1 Basic Safety Training
2 Personal Survival Techniques
3 Fire Prevention and Fire Fighting
4 Elementary First Aid
5 Personal Safety and Social Responsibilities
6 Proficiency in Fast Rescue Boat
7 Advance Firefighting
8 Medical First Aid
9 Proficiency in Survival Craft and Rescue Boats
10 Radar Observation
11 Automatic Radar Plotting
12 ARPA Simulator

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 14 Radar Simulator
13 Ship Security Officer (SSO)/ Security Awareness(SAT) / Designated Security Duties(SDSD) 1/18/2014 1/17/2019
14 Bridge Resource Management
15 Engine Room Resource Management
16 Global Maritime Distress Safety System (GMDSS)
17 Food handling Certificate (COOK)
18 Medical Care Onboard
19 BOSIET
20 HUET
21 DP Maintenance
22 DP Simulator
23 Rigging & Slinging Certificate
24 HLO / HLA
25 Proficiency in Fast Rescue Boat (PFRB)
26 Electronic Chart Display AND Information System (ECDIS)
NEXT OF KIN (NOK) DETAILS (to be contacted in case of Emergency)
Name Relationship

Address
Tel. No
SPOUSE PARTICULARS
Spouse Name Date of Birth

Address
Tel. No
DEPENDENTS / CHILDREN PARTICULARS
No. Name Relationship Date of Birth Age
1
2
3
4
5

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 L3-CREW-FRM-56 CREW APPLICATION REV 0

SEA TIME EXPERIENCE

Area of Type of Client Period (d-mmm-yy)

No Name of Vessel Rank Vessel Type GRT / HP Company
Operation Operation (Charterers Name) From To
1
2
3
4
5
6
7
8
9
10

13
14
15
16
17
18
19
20
21
22
23
24
25

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L3-CREW-FRM-56 CREW APPLICATION REV 0
CREW APPLICATION

REVISION LOG

Initials in the approval boxes confirm that the document has been approved.
Only the last 3 revision logs are printed on this document. Refer to the Document Management System (DMS) for the full revision log
and electronic approvals.

Rev Effective Description of Changes Issued By

0 1-Nov-18 Released for Manual’s Version 2 Sandra J.
m (DMS) for the full revision log

Approved By
Mohsen M.