LOTUS SHIPMANAGEMENT INC.

7th Floor, S & L Building I

1500 Roxas Boulevard, Ermita
Manila, Philippines 1000
APPLICATION FORM / PERSONAL DATA FORM

DATE APPLIED: O5 - 25 - 2022

POSITION APPLIED FOR: 2nd officer OTHER ( IF ANY ):

FULL NAME: Cabug Limar Brioso GENDER:

( SURNAME) ( FIRST NAME ) (MIDDLE NAME )

PERMANENT ADDRESS: Prk.1, rizal jimenez,

( CITY )
Misamis occidental
( PROVINCE )
TEL NO.: MOBILE NO.: 09391009039 RELIGION: Christian
NATIONALITY: Filipino PLACE OF BIRTH: Jimenez, misamis DATE OF BIRTH: 17/ 07/ 1973
occidental
(DAY / MONTH/ YEAR)
CIVIL STATUS: Married EMAIL ADDRESS: limarcabug@gmail.com ZIP CODE: 7204

HEIGHT (CM): 170 cm WEIGHT (KG): 75 kg BLOOD GROUP: O SAFETY SHOES: 9 BOILER SUIT SIZE: L

SSS NO.: 33-2419490-3 TIN NO.: PHILHEALTH NO.: 12-050700297-3 PAG-IBIG NO.: 1212-1995-4787

POEA E-REGISTRATION NO.: 0152114-94 MARINA SRN NO.: 7307170006

PASSPORT NO.: P8600693A DATE OF ISSUE: 04/ 09/ 2018 DATE OF EXPIRY: 03/ 09/ 2028
(DAY / MONTH/ YEAR) (DAY / MONTH/ YEAR)
SIRB NO.: C1335923 DATE OF ISSUE: 04/ 09/ 2018 DATE OF EXPIRY: 01/ 09/ 2028
(DAY / MONTH/ YEAR) (DAY / MONTH/ YEAR)
COVID-19 VACCINE
FIRST DOSE SECOND DOSE
VACCINATION BRAND: Pfizer VACCINATION BRAND: Pfizer
DATE OF VACCINE DOSE: December 2, 2021 DATE OF VACCINE DOSE: December 23, 2021
VACCINATION FACILITY: CHO-4 VACCINATION FACILITY: CHO-4

EDUCATIONAL BACKGROUND
LEVEL SCHOOL NAME FROM TO COURSE
ELEMENTARY Jimenez central school 1980 1986 Elementary
HIGHSCHOOL College of saint john the baftist 1987 1990 High school
COLLEGE Misamis institute of technology 1991 1994 College
VOCATIONAL

FAMILY DETAILS
NEXT OF KIN / ALLOTTEE: Cabug, Anita Ang RELATIONSHIP: Wife
( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 02/ 04/ 1976 PLACE OF BIRTH: Kapalong, davao del norte MOBILE NO.: 09154579560
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental

NAME OF SPOUSE/PARTNER: Cabug, Anita Ang

( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 02/ 04/ 1976 PLACE OF BIRTH: Kapalong, davao del norte MOBILE NO.: 09154579560
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental
 NAME OF MOTHER: Cabug, Lilian Brioso
( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 27/ 07/ 1948 PLACE OF BIRTH: Sinacaban, misamis MOBILE NO.:
occidental
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental

NAME OF FATHER: Cabug, Marcelino Israel:

( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 02/ 06/ 1948 PLACE OF BIRTH: Sinacaban, misamis MOBILE NO.: 09999741577
occidental
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental

BENEFICIARY: Cabug, Anita Ang RELATIONSHIP: Wife

( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 02/ 04/ 1976 PLACE OF BIRTH: Kapalong, davao del norte MOBILE NO.: 09154579560
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental

CHILD/CHILDREN DETAILS
FIRST CHILD: Cabug, Jino Brandon Ang
( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 08/ 09/ 2001 PLACE OF BIRTH: Tagum, davao del norte
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental

SECOND CHILD: Cabug, Nico Shanzen Ang

( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: 30/ 04/ 2007 PLACE OF BIRTH: Jimenez, misamis occidental
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS: Prk. 1, rizal jimenez, misamis occidental

THIRD CHILD:
( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: PLACE OF BIRTH:
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS:

FOURTH CHILD:
( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: PLACE OF BIRTH:
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS:

FIFTH CHILD:
( SURNAME / FIRST / MIDDLE )
DATE OF BIRTH: PLACE OF BIRTH:
(DAY / MONTH/ YEAR)
COMPLETE ADDRESS:
 PRINCIPAL GROSS ENGINE MAKE SIGN ON DATE SIGN OFF DATE REASON LAST
VESSEL POSITION/RANK TYPE OF VESSEL YEAR BUILT (DAY/MONTH/YEAR)
AGENCY TONNAGE & BHP/KW (DAY/MONTH/YEAR) FOR LIVING SALARY
Amansinaya shipping
Finish
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shipmanagement inc. RECORD

Agean bulk co. Inc.

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Two months
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ship sold out
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Agean bulk co. Inc.
Finish
Magsaysay maritime Alfios Able seaman Bulk carrier 2012 34,554 9,960 09/12/2015 16/01/2017 Ś1,480
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corp.
Agean bulk co. Inc.
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Magsaysay maritime Inception Able seaman Bulk carrier 2012 43,754 15,050 13/10/2014 16/10/2015 Ś1,480
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corp.
Agean bulk co. Inc.
Finish
Magsaysay maritime Arkas Able seaman Bulk carrier 2012 34,554 9,960 02/03/2012 07/09/2013 Ś1,700
contract
corp.
Agean bulk co. Inc.
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Magsaysay maritime Agonistis Able seaman Bulk carrier 2011 34,374 13,560 12/09/2010 11/09/2011 Ś1,480
contract
corp.
Agean bulk co. Inc.
Finish
Magsaysay martime Hephaestus Able seaman Bulk carrier 2007 39,978 12,000 15/02/2009 09/01/2010 Ś1,700
contract
corp.
Agean bulk co. Inc.
Finish
Magsaysay maritime Evanthia Able seaman Bulk carrier 2007 39,978 12,000 13/12/2007 20/09/2008 Ś1,480
contract
corp.
Agean bulk co. Inc.
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Magsaysay maritime Afovos Able seaman Bulk carrier 2007 39,978 12,000 09/09/2006 16/06/2007 Ś1,700
contract
corp. REMARKS:

Agean bulk co. Inc.

Finish
Magsaysay maritime Evanthia Ordinary seaman Bulk carrier 2007 39,978 12,000 04/08/2005 24/05/2006 Ś1,200
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corp.