Application for Employment Photo

(optional)

Personal Data
Full Name (in English) Position Applied
Nationality Date of Birth DD - MM - YY Place of Birth
Course/ Year
School
Degree Graduated
Applicant's Home
Permanent
Telephone Mobile
Address
Email
Civil Status *Single *Married *Separated *Widowed
*(Delete as
English Spoken Written Understanding appropriate)
Ability *Yes/No *Yes/No *Yes/No
Height (cm) Weight (kg) Shoes size (UK) Coverall (S/M/L/2L/3L)
Next of Kin
Full Name (in English) Gender Telephone / Email
(relationship)
Male / Female
*(Delete as appropriate)

Contact Person in case of Emergency Relationship

Telephone
Address
Mobile
Documents
Number Date of Issue Date Valid Until Place of Issue
Passport DD - MM - YY DD - MM - YY
Seaman Book DD - MM - YY DD - MM - YY
USA Visa C1/D DD - MM - YY DD - MM - YY
AUS MCV (e-visa) DD - MM - YY DD - MM - YY

Certificates (for Officers)

Capacity Number Date of Issue Date Valid Until Place of Issue
National Certificate of Competency DD - MM - YY DD - MM - YY
National GMDSS (Deck Officers, IV/2) DD - MM - YY DD - MM - YY
National CoP for SSO (C/O & C/E, VI/5) DD - MM - YY DD - MM - YY
Hong Kong Licence Endorsement DD - MM - YY DD - MM - YY
Certificates (for Ratings)
Capacity Number Date of Issue Date Valid Until Place of Issue
Watch Keeping Certificate (II/4 or III/4) DD - MM - YY DD - MM - YY
Able Seafarer Deck/Engine (II5 or III/5) DD - MM - YY DD - MM - YY
Certificate as Ship's Cook DD - MM - YY DD - MM - YY

Trainings
Course (STCW Reg) Number Date of Issue Date Valid Until Place of Issue
Basic Training (VI/1) DD - MM - YY DD - MM - YY
Survival Craft & Rescue Boat (VI/2) DD - MM - YY DD - MM - YY
Fast Rescue Boat Training (VI/2) DD - MM - YY DD - MM - YY
Free Fall Life Boat Training (where fitted) DD - MM - YY DD - MM - YY
Advanced Fire-Fighting (VI/3) DD - MM - YY DD - MM - YY
Medical First Aid (VI/4) DD - MM - YY DD - MM - YY
Medical Care on Board (VI/4) DD - MM - YY DD - MM - YY
Designated Security Duty Training (VI/6) DD - MM - YY DD - MM - YY
Bridge Team Resource Management (simulator) DD - MM - YY DD - MM - YY
Pacific Basin MRM Training - Swedish P&I Club DD - MM - YY DD - MM - YY
ECDIS (Generic IMO 1.27) 2010 Amendment DD - MM - YY DD - MM - YY
ECDIS (Type Specific) DD - MM - YY DD - MM - YY
Ship Handling & Manoeuvring DD - MM - YY DD - MM - YY

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Sea Experience: (Last 5 Years) (Most recent experience on top line)
IMO GRT Main Engine Reason for
Company Vessel Type* BHP Rank Sign on Sign off
Number DWT Type & Model Leaving

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

DD - MM - YY DD - MM - YY

* Use the following abbreviations for type of vessel: *Engineers to record make/model of engines.
TKR – Tanker RoRo – Roll-On Roll-Off CONT – Container e. g. “MAN 14V52/55A” or “Sulzer 5RTA58”
BLK – Bulk Carrier LPG – Liquid Petrol Gas PCC – Pure Car Carrier
LOG – Log Carrier GC – General Cargo

Medical History
It is of utmost importance that all major Illnesses, Injuries and Physical limitations must be declared, the company assures that it will not affect your applicaiton as long as you are Medically fit
for sea duty. The Company is entitled to refuse any claim for treatment, cost or any other insured benefits if a complete statement of all previous major Illnesses and Injuries has not been
disclosed.

A. Have you ever signed off a ship due to Medical reasons? Yes/No*
Name of Vessel Date of Occurrence Place of Occurrence Brief description of Illness/Injury

B. Have you undergone any Medical Operation in the past? Yes/No*

Details of Medical Operation Date Period of Disability Present Condition

C. Have you consulted a Doctor for Illness or Injury during the last 12 months? Yes/No*
Details of Illness or Injury Date Therapy / Treatment

D. Do you have any Health or Disability problem? Yes/No*

Details of Health or Disability problem Date of Occurrence

E. Do you have allergies? Please elaborate, it is important to declare your physical limitation in case of onboard medication
Food Yes/No*
Antibiotic Yes/No*
Other Medicine Yes/No*
Fumes, Dust, Smoke Yes/No*
Do you have maintenance
Yes/No*
medicine to bring onboard?
Do you agree to share above Medical information to your fellow seafarers onboard the ship? Yes/No*
F. General information
1. Have you previously abused Drugs? Yes/No*
2. Have you ever been denied a Foreign Visa? If yes, state which country and reason (If known). Yes/No*
3. Have you been the subject of a Court of Enquiry or been involved in a Maritime Accident? If yes, please attach details. Yes/No*
(Please attach separate sheets if space is insufficient in the Application for Employment Form)
I hereby declare that the above information, including Medical History, is true and correct.
Place:

P01 Issue/Rev: 01.03.2019 / 10 (B)

Date: DD - MM - YY Signature:

*(Delete as appropriate)

P01 Issue/Rev: 01.03.2019 / 10 (B)

 Photo
(optional)

*(Delete as
appropriate)

Telephone / Email

Place of Issue

Place of Issue

Place of Issue

Place of Issue

P01 Issue/Rev: 01.03.2019 / 10 (B)

 Reason for
Leaving

e declared, the company assures that it will not affect your applicaiton as long as you are Medically fit
insured benefits if a complete statement of all previous major Illnesses and Injuries has not been

Yes/No*
Brief description of Illness/Injury

Yes/No*
Present Condition

Yes/No*
Therapy / Treatment

Yes/No*
Date of Occurrence

declare your physical limitation in case of onboard medication

Yes/No*

Yes/No*
Yes/No*
Yes/No*

P01 Issue/Rev: 01.03.2019 / 10 (B)