FILIPINAS KALAYAAN OVERSEAS SHIPPING INC.

No. 3 Mascardo St. Brgy. Singkamas,

RECOMMENDED BY: Lapaz Village, Makati City
Tel. No. 8899-95-73 / 8899-33-50

DATE :

APPLICATION FORM

POSITION APPLIED FOR :

ALTERNATIVE POSITION :
DATE AVAILABLE :

(SURNAME) (FIRST NAME) (MIDDLE NAME) (AGE) (CIVIL STATUS)

(DATE OF BIRTH) (PLACE OF BIRTH) (NO. OF CHILDREN) (HEIGHT) (WEIGHT)

CONTACT ADDRESS : TEL. No.

CEL. No.
HOME ADDRESS : TEL. No.
CEL. No.

SRC ID No. PLACE/DATE ISSUED

SIRB No. : DATE ISSUED : DATE EXPIRED :
PASSPORT No. : DATE ISSUED : DATE EXPIRED :
C.O.C. DATE ISSUED : DATE EXPIRED :
C.O.P. (RATINGS ONLY) : DATE ISSUED :
NC-I NC-III DATE ISSUED : DATE EXPIRED :

BENEFICIARIES
NAME : RELATIONSHIP :
ADDRESS : TEL. No.:
CEL. No.:

SECONDARY ADDRESS
NAME OF PARENTS OR SISTER: RELATIONSHIP:
ADDRESS : TEL. No.:
CEL. No.:

LICENSE GRADE / CLASS NUMBER DATE ISSUED EXPIRY DATE

*PLEASE CHECK ALL TRAINING CERTIFICATE FOR STCW '95 REQUIREMENTS*

( ) ADVANCE FIREFIGHTING ( ) BT ( ) CULINARY-MLC 2006 ( ) DECK WATCH KEEPING

( ) ENGINE WATCH KEEPING ( ) ECDIS ( ) HAZMAT ( ) MARPOL I-VI ( ) MLC ( ) MEFA
( ) MECA ( ) MESSMAN-MLC 2006 ( ) PADAMS ( ) PSCRB ( ) SSO ( ) SDSD ( ) TRIM & STABILITY

NOTE : WE'LL ANNUL OUR EMPLOYMENT CONTRACT IF THERE IS ANY FAULTY OR INTENTIONAL ITEMS HERE.

*SKETCH OF HOME*
 SEA GOING EXPERIENCE (FROM PREVIOUS TO PRESENT)

NATIONALITY
YR TYPE OF TRADE TOTAL TOTAL
VESSEL NAME RANK FROM TILL GRT MAIN ENG. H/P AGENCY Master or
BUILT VESSEL ROUTE SALARY MONTH Principal C/Engr

HIGHEST SCHOLASTIC RECORD :

SCHOOL : FROM : TO :
DEGREE IF ANY : OTHER SKILLS :
VOCATIONAL TRAINING COMPLETED :
REFERENCE NAME & ADDRESS : ANY SPECIAL CERT.:
SIGNATURE OF APPLICANT