SEAFARER INFORMATION SHEET

PERSONAL INFORMATION
Name (Surname, First Name, Middle Name):
Full Name in Native Language: Other Names Used:
Social Media Account Name: Facebook: Others:
Sex: [ ] Male [ ] Female Marital Status:
Birthday: Place of Birth:
Nationalities:
ADDRESS INFORMATION
National Identification Number: PTC-
Home Address:
City: Postal Zone / Zip Code: Country:
Mailing Address:7458-60 Bagtikan St. San Antonio Village
City: Makati Postal Zone / Zip Code: 1203 Country: Philippines
Home Phone Number: Work Phone Number: 02 898-1111
Cellphone Number: Work Fax Number: 02 898-1107
Email Address:
PASSPORT INFORMATION
Passport Number: Passport Book Number:
Country/Authority that Issued Passport:
City Where Issued: Country Where Issued:
Issuance Date: Expiration Date:
Have you ever lost a passport or had one stolen? [ ] YES [ ] NO
If yes, indicate the:
Place of Issuance: Passport Number:
Issuance Date: Expiration Date:
Year Lost: Reason:
FAMILY INFORMATION
Father's Name (Surname, First Name, Middle Name):
Birthday: Is your father in the US? [ ] YES, status: __________________ [ ] NO
Mother's Maiden Name (Surname, First Name, Middle Name):
Birthday: Is your mother in the US? [ ] YES, status: __________________ [ ] NO
Do you have any immediate relatives, not including your parents in the US? (sister/brother/son/daugther) [ ] YES [ ] NO
If yes, indicate the:
Name (Surname, First Name, Middle Name) :
Status:
Do you have any relatives in the US? [ ] YES [ ] NO
Spouse's Maiden Name (Surname, First Name, Middle Name):
Birthday: Nationality:
City of Birth: Country of Birth:
Spouse's Address:
EDUCATIONAL BACKGROUND
Name of School Address Course Inclusive Dates (mm.dd.yy)
College / Vocational From: To:
Secondary From: To:

LS 051 Rev. No.: 01 Rev. Date: August 7, 2019

 CURRENT EMPLOYMENT INFORMATION
Current Position: Principal:
Present Employer: [ ] PTC [ ] MSC
Start date with current PTC/MSC (mm.yyyy) :
Briefly describe your duties:
Previous travels for the past 5 years (Countries) :
1. 7. 13. 19. 25.
2. 8. 14. 20. 26.
3. 9. 15. 21. 27.
4. 10. 16. 22. 28.
5. 11. 17. 23. 29.
6. 12. 18. 24. 30.

PREVIOUS EMPLOYMENT INFORMATION

Previous Employer 1:
Address:
Telephone No.:
Job Title:
Supervisor's Name:
Start of Employment (mm.dd.yy): End of Employment (mm.dd.yy) :
Duties and Reponsibilities:
Previous Employer 2 (Optional) :
Address:
Telephone No.:
Job Title:
Supervisor's Name: End of Employment (mm.dd.yy) :
Date of Employment (mm.dd.yy) :
Duties and Reponsibilities:
TRAVEL INFORMATION
Have you ever been in the US? [ ] YES [ ] NO
If yes, indicate the:
Five (5) Most recent visit:
Date of visit (mm.yyyy) Number of Days

Have you even been issued a US Visa? [ ] YES [ ] NO

If yes, indicate the:
Type of Visa: Place of Issue:
Have you even been denied of a US Visa? [ ] YES [ ] NO
If yes, indicate the:
Year Denied:
Type of Visa: Reason of non-issuance:
Have you ever lost a US Visa? [ ] YES [ ] NO
If yes, indicate the:
Year Lost:
Issuance Date: Expiration Date:
Place of Issuance: Reason:

Crewing Personnel to be contacted (PIC):

Monthly Salary:

LS 051 Rev. No.: 01 Rev. Date: August 7, 2019