POM INESS NO. 001-C / REV. 18 /OCT 22 2018 NAESS SHIPPING PHILIPPINES, INC. INFORMATION SHEET FOR SHIPBOARD EMPLOYMENT INSTRUCTION: PRINT ALL ENTRIES CLEARLY. DATES SHOULD BE IN THE ORDER OF DAYIMONTHIYEAR (MONTH SHOULD Be |W TEXT FORMAT) FILLIN DATA CONLETELY. TENS THAT ARE NOT APPLICABLE SHOULD OE MARKED AS WA [POSITION APPLIED FOR - — oS Please attach 2x2" Recent Photo 2. NAME (LAST) (FIRST) (MIDDLE) | S ADORESS lc cat no > [6. TEL. NO: jr erRTDATE [earns Puace lo Evan: 10 cit srarus 7 ii TTTN FEST 15 PRSTIS Fe PITAL cy 76, BENEFOARY 7, RELATIONSHP 6 ADDRESS 9, CEL.NO 20 ALLOTTEE a. RELATIONS 22 ADDRESS ba. cEL No [2t CONTACT NGAGE OF EMERGENCY 2s, RELATIONS [es aboaess 7. CEL. NO r - 5 ificate 28, LICENSE-OFFICERS 2. General pean en TYPE [LIGENSENO.[ GRADE | ISSUED | EXPIRE] [CERT.NO[ ISSUED | EXPIRE PHILPPINES FLAG STATE 30. SEAFARER’S IDENTIFICATION and RECORD BOOK (SIRB) TYPE ‘SIRB NO. DATE ISSUED EXPIRE PHILIPPINES: FLAG STATE: ‘31. STCW CERTIFICATE TESDA COC/ MARINA COP Certificate | ISSUED COP Certificate ISSUED ROMBER: BT WECA ISSUED CRE. BTFLGT DPRES FRE BTFOC TNITATIONS TF ANY ‘ATFF ATFO MEFA ATFC ATFLGT ‘STSDSO 32, POEA DATA SRCNO.: POEA RATING: DATE ISSUED: 33. TRAVEL DATA PASSPORT NO. PP ISSUED: PP EXPIRATION: USA. VISA VISA ISSUED. VISA EXPIRATION: 34. EDUCATIONAL BACKGROUND SCHOOL ATTENDED YEAR GRADUATED DEGREE EARNED 35, SIZE of WORKING CLOTHING ‘SHOES___in PARKA cS OM ol cxt | BOWERSUIT OS OM OL OXL Weight: BMI: Height: (See continuation at the back)Form NAESS NO, OO1.C /REV 19 /OCT 22 2018 36. SHIPBOARD EXPERIENCE VEsseL Tre | FLAG |yencin| cnt | ann [-HERGE COVERED | cour 37. TRAINING RECORD ‘COURSE (6) TAKEN TRAINING CENTER CERTIFICATE NO. | \SGUED 38. FAMILY DETAILS Married: NoO Yes tyes, Wie's Name Date Married Wee's Place/ DOB : No of cheren Please give their names and dates of bith, Neme DOB Name DOB 4) 4) 2) 5) 3) 6) ‘Thereby declare that all the above-mentioned information is true and correct to the extent of my knowledge and Iwill solely be “SIGNATURE OVER PRINTED NAME NOTE: A.) SERVICE CERTIFICATION FROM PREVIOUS EMPLOYERS, responsible for any discrepancy found in them, Emal Adéress: Contact No: Ms. Maricel~09618763109 DATE crultme s.comph (Ms. Bien 09088125198.