M&S (Guernsey) Limited Crew Details

Crew Member Details

Employee Name:
Position:
Vessel:
Nationality:
Date of Birth:
Passport Number: Passport Expiry:
National Insurance
Number
US Visa No, if app: US Visa Expiry, if app:

Home Address:

Repatriation Destination:

Mobile No:
Email:
Start Date: Port of Embarkation:

Next of Kin
Name:
Address:

Relationship:
Home Phone:
Secondary number:
Email:
Any Other Information:

Bank Details
Account Holders Name:
Name of Bank:
Address of Bank:

Account Number:
IBAN Code:

Rev 2 08.2007
 Swift Code/BICC Code:
Further information:

Certificate Details
Name as it appears (if different from above):
Cert Type: (Master, Ch Eng) CoC n°:

Issue Date: Expiry Date:

GMDSS Type: GMDSS Expiry Date:

Medical Care Onboard Flag State Endorsement

Expiry Date: Exp Date:
ENG1 / medical certificate valid to date:
If no CoC, does employee have basic STCW95 4 pack?
Have you checked references and kept proof on file?

Medical Details
Any pre-existing medical condition, allergy or
prescribed medicine required?

Rev 2 08.2007