830a_Crew Application Form - Sea Service Rev 24 Feb 2021

M.E. TYPE NO. OF CARGO SIGN ON * SIGN OFF NO. OF SIGN OFF
MANNING AGENCY PRINCIPAL RANK VESSEL NAME FLAG TYPE OF VESSEL DWT GRT (MAKER) M.E. PS/KW CRANES (dd/mm/yy) (dd/mm/yy) MONTHS REASON

* list all sea service including cadet ship

 Rev:
830a_Crew Application Form 30 April 2021

POSITION APPLIED FOR / 2nd OPTION DATE OF

APPLICATION

PERSONAL DETAILS

SURNAME
GIVEN NAME
MIDDLE NAME
DATE / PLACE OF BIRTH
NATIONALITY INSERT PHOTO
MARITAL STATUS GENDER male
DATE OF AVAILABILITY
(to be filled out by the Recruitment Officer)
HEIGHT (cm): cm WEIGHT (kg): kg BMI:

CONTACT INFORMATION

HOME ADDRESS w/ ZIP Code

MOBILE & LANDLINE PHONE NUMBERS:

*E-MAIL / * SKYPE ID
NEAREST AIRPORT

NEXT OF KIN DETAILS (NOK)

RELATIONSHIP
SURNAME/GIVEN NAME/MIDDLE NAME
NOK ADDRESS
NOK CONTACT NUMBER

PRE-SEA EDUCATION
NAME OF SCHOOL / ACADEMY QUALIFICATION / DEGREE FROM TO

TRAVEL DOCUMENTS

NAME OF DOCUMENT NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY

NATIONAL PASSPORT
NATIONAL SEAMANS BOOK
US C1/D VISA
MEDICAL REPORT
YELLOW FEVER VACCINATION CERTIFICATE
POLIO VACCINATION CERTIFICATE

CERTIFICATES

NAME OF DOCUMENT SERIAL NUMBER CAPACITY DATE OF ISSUE DATE OF EXPIRY

COC
ENDORSEMENT
GMDSS / GOC
* required

IMO / STCW CERTIFICATES

NAME OF DOCUMENT NUMBER PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
ADVANCED FIRE FIGHTING
BASIC SAFETY TRAINING
ECDIS
BRIDGE TEAM & RESOURCE MANAGEMENT

HUMAN ELEMENT, LEADERSHIP & MANAGEMENT (HELM)

ENGINE TEAM & RESOURCE MANAGEMENT

MEDICAL CARE
PROFICIENCY IN SURVIVAL CRAFT
SECURITY AWARENESS

SECURITY WITH DESIGNATED SECURITY DUTIES

SHIP SECURITY OFFICER

SHIPBOARD SAFETY OFFICER (SBSO)
TANKER FAMILIARIZATION

ADVANCED TRAINING FOR OIL TANKER CARGO OPERATION

ADVANCED TRAINING FOR CHEMICAL TANKER CARGO

OPERATION

NON-STCW CERTIFICATES
NAME OF THE DOCUMENT PLACE OF ISSUE DATE OF ISSUE DATE OF EXPIRY
HAZMAT(Acc US CFR)
RO-RO PASSENGER SHIPS
MAN ELECTRONIC INJECTED ME
SULZER RT FLEX
HIGH VOLTAGE / MEDIUM VOLTAGE
ECDIS TYPE SPECIFIC 1
ECDIS TYPE SPECIFIC 2
INCIDENT INVESTIGATION COURSE

OTHER QUALIFICATIONS AND SHORE BASED EMPLOYMENT

DECLARATION – applicable for Filipino nationality only

I hereby agree to declare the following to ZEABORN Marine Services (Philippines) Corp.:

YES NO
1. Are you suffering from or did you suffer from a medical condition, illness or injury?
If yes, please specify

2. Are you taking any prescribed or unprescribed medications?

If yes, please specify

I confirm that any misdeclaration and/or concealment will disqualify me from any entitlement related to my application or future employment, and therefore render all
agreements null and void.

I certify that the above information and attached sea service record are true and accurate; and that any false information would lead to the nullity and denial of this
application.

That all Certificates of Competence or Licenses presented have never been revoked and/or suspended.

In compliance with the Data Privacy Act of 2012 (RA 10173), I agree that ALL information regarding myself may be shared for hiring / processing and documentation
purposes with the principal and all internal interested parties, Philippine Government Agencies (e.g. POEA, OWWA, DFA, MARINA, SSS) and other external interested
parties (e.g. AMOSUP, P&I Clubs and Correspondents, HMO, Flag State Authorities, Medical Assessment and Diagnostic Centers).

DATE 10/20/2021
PRINT NAME + SIGNATURE