MANILA : Pilgrim 111, Aguirre St, Makati City, Metro Manila

ILOILO : 3rd Floor Robinsons Place Iloilo, Mabini Street,

Corner De Leon St., Iloilo City, 5000 Iloilo
CEBU : 2nd Floor Bldg 3, The Persimmon Plus MJ Cuenco Avenue
Corner Gil Tudtud Street Mabolo Cebu City

Once done, resend to: edsel.tesio@jebsen-ptc.com.ph

APPLICATION GENERAL INFORMATION SHEET

Name (First/ Middle/Last ) : Position: Age:

Current address :
Mailing Address : Contact Number :
Civil Status : Height: : Email Address :
Birthdate : Weight: : Civil Status :
Birthplace : Religion: : Color of Eyes :
Mother : Date of Birth: : Blood Type :
Father : Date of Birth: : Tax Status :
Spouse : Date of Birth: : SRC :
Next of Kin : Date of Birth: : SRC POS. :

: TIN. : SSS No. :

Statutory Infos
Pag-ibig No. : Philhealth No :

: Details / Number Type / Description Contact Person

Contact Person Infos

: Name Date of Birth Age

Children

: School Attended Degree Year Graduated

Education

: Number Issued Date Validity Date Place of Issue

Other Document / ID

: Issued Validity Clinic

Health Declaration

: Issued Validity Clinic

Crew Vaccines

: Results Issued Validity Clinic

Pre Medical

Country Book Type Number Issued Validity

Books :

Country Type No. Issued Validity

VISAs :

Highest License Held: :

License Capacity Issuing Ofc. License No. Lic. Date ID number Issued Validity

Qualification/Training Certificate:

License Capacity Issuing Office Number Issued Validity

Work Experiences:

WORKING DATES Main

Rank/Position Vessel Type GRT Vessel Name Company / Agency BHP Reason for Leaving
Onboard Disembarked Engine Type

(USE EXTRA SHEET IF BLANK SPACES ARE NOT ENOUGH)

Land Based Experience:

From To Position Company Name Reason for Leaving

Reference:

Name Work Position Address Contact Number Relationship

Name of the FRIENDS/ RELATIVES in this company:

Person to be notified in case of emergency / Tel no: / Relationship : ________________________________________________________________________________________________
through what channel you application made? (Please check)

c Applied on own c Postings/Ads c Job fair c Referrals c Others, please specify: _________________

I hereby certify that the foregoing answers and statements are true and correct to the best of my knowledge and belief.
I am aware that any falsification shall be a cause of dismissal in case I am employed

Signature Over Printed Name

______