MD-CSE-001 (06/21) Page 1 of 3

GRAND SEAS SHIPPING, CORP.

EMPLOYMENT APPLICATION FORM
DATE OF APPLICATION REFERRED BY
Recent
POSITION APPLIED FOR VESSEL TYPE Photo

FIRST NAME MIDDLE NAME LAST NAME

Directions: Write legibly. Do not leave any item unanswered. Put N/A on items that are not applicable.
PERSONAL INFORMATION
CITY ADDRESS LANDLINE/MOBILE NO.

PROVINCIAL ADDRESS LANDLINE/MOBILE NO.

SEX AGE DATE OF BIRTH PLACE OF BIRTH NATIONALITY RELIGION

CIVIL STATUS TIN: SSS No. PHILHEALTH NO. PAG-IBIG NO.

HT. WT. BOILER SUIT SIZE: SHOE SIZE: DRIVER’S LICENSE

NEXT-OF-KIN RELATIONSHIP LANDLINE/MOBILE NO.

ADDRESS

EDUCATIONAL BACKGROUND
LEVEL SCHOOL/EDUCATIONAL INSTITUTION YEARS INCLUSIVE DEGREE/HONORS/ AWARDS
FROM TO EARNED
HIGH Name
SCHOOL
Address

VOCATIONAL Name
SCHOOL
Address

COLLEGE Name

Address

CERTIFICATES OF COMPETENCY
ISSUING AUTHORITY RANK LICENSE NO. DATE OF ISSUE DATE OF EXPIRY
NATIONAL (D-COC)
NATIONAL (COC/COE)
NAVIGATIONAL WATCH
MARINA SID

OTHER CERTIFICATES / DOCUMENTS

TYPE CERTIFICATE DATE OF ISSUE DATE OF EXPIRY

NO.
SEAMAN’S BOOK (SIRB)
REGISTRATION CERTIFICATE (SRC)
YELLOW FEVER EXPIRES ON:

MARINA CERTIFICATES
COURSES CERTIFICATE NO. DATE OF ISSUE DATE OF EXPIRY
Advance Training for Chemical (ATOC) with COP

Advanced Training in Fire Fighting (ATFF) with COP

Advanced Training for Oil Tanker Cargo Operations
(ATOT) with COP
Advanced Training for Chemical Tanker Cargo
Operations (ATCT) with COP
Advance Training for Liquefied Gas Tanker Cargo
Operations (ATLGT)
Automatic Radar Plotting Aid (ARPA)
Basic Training (BT) with COP

Distribution – Marine Department

 MD-CSE-001 (06/21) Page 2 of 3
COURSES CERTIFICATE NO. DATE OF ISSUE DATE OF EXPIRY
Basic Training (BT) Refresher
Basic Training For Oil and Chemical Tanker Cargo
Operation (BTOCT) with COP
Bridge Teamwork Management (BTM)/ Bridge Resource
Management (BRM)
Electronic Chart Display and Electronic System – ECDIS
(as applicable)
Global Maritime Distress & Safety System (GMDSS)
INMARSAT (as applicable)
MARPOL 73/78 Annex I-VI (CONSOLIDATED)
Medical Emergency First Aid (MEFA) with COP
Medical Care ( MECA ) with COP
Passenger Ship Crowd Management Training
Passenger Ship Crisis Management and Human Behavior
Training
Proficiency on Survival Craft &Rescue Boat (PSCRB)
Radar Observation and Plotting (ROP)
Radar Simulator Course (RSC)
Ship Security Awareness Training & Seafarers with
Designated Security Duties (SDSD) with COP
Ship Security Officer Course (SSO) with COP
Shipboard Safety Officer (SBS)
Ship Restricted Radio Telephone Operator’s Course
(SRROC)
Others: (please specify)

SEA EXPERIENCE
Start with your most recent employment.
VESSEL TYPE/ FLAG GRT ENGINE PRINCIPAL/ RANK SIGN ON SIGN OFF REASON
STATE MAKE/BHP MANNING
AGENCY

MEDICAL HISTORY
It is important that all illnesses (minor and major) should be stated. The Company is entitled to refuse any claim for treatment, cost or any
other insured benefits if a complete statement of all previous illnesses has not been given.
(A) Please give details of any present/ past health problems:

Distribution – Marine Department

 MD-CSE-001 (06/21) Page 3 of 3
* This may include self-assessment of your present medical conditions ((like showing signs of COVID19 symptoms (e.g. fever, dry
cough, colds, headache, diarrhea, body aches/fatigue): (specify symptoms)
(B) Please give details of any medical benefits claimed:

APPLICANT’S SIGNATURE: INTERVIEWER’S SIGNATURE:

________________ DATE: ____________ ____________ DATE: ____________

With my signature, I hereby attest and certify that all information as Position
stated above are true and correct, and that any false statement or
undisclosed material and/or information with regards to my past or
present employment and medical history will disqualify me from any
employment, benefits and/or claims.

That, I further hold myself liable for perjury, falsehood,

misrepresentation or omission or any act of dishonesty for any
fraudulent, false, and tampered documents that I have submitted and
hereby indemnify the company against any claims or demands
whatsoever which may at any time be made against the company, or
any of them by reason of any fault, defect, omission, or inaccuracy in
the content of the Certificates or other documents.

That, I am fully aware that any misrepresentation is a ground for

prosecution / administrative penalties or sanctions.

That I attest to the truthfulness of this undertaking and I submit to the

legal and administrative consequence thereof if the statements above
are wanting in truth and substance.

Distribution – Marine Department