Capital Ship Management Corp.

HRM / SECTION 2 / F-001

Issue Date : 01/06/2022
Revision: 00
Authorized by: DPA
Applicant’s Surname: Applicant’s First Name:

Rank: Date of birth: Place of birth: PHOTO

License Grade: Age:
Home address:

Approximate Weight : Height :

Marital Single Married Next of kin: Telephone: Mobile:
Status: Relationship: E-Mail:
DOCUMENTS NUMBER ISSUING AUTHORITY Date Issued Expiry Date
Passport
Seaman’s book
National License/Diploma
S T C W Endorsement/COC
Flag Endorsement
Medical Fitness Certificate

TRAINING CERTIFICATES YES NO ISSUING AUTHORITY Date Issued Expiry Date

FIRE PREVENTION & FIRE FIGHTING
PERSONAL SURVIVAL TECHNIQUES
PERSONAL SAFETY AND SOCIAL RESPONSIBILITIES
ELEMENTARY FIRST AID
SURVIVAL CRAFT & RESCUE BOATS VI/
ADVANCED FIRE FIGHTING VI/
MEDICAL FIRST AID VI/
MEDICAL CARE VI/
RADAR, ARPA, BRIDGE TEAMWORK A-I/12 A-I
GMDSS (GO)
PREVENTION OF POLLUTION A-II/1 A-
HANDLING OF DANGEROUS CARGOES A-II/1 A-
MARITIME ENGLISH A-II/1 A-
TANKER FAMILIARIZATION V/ 1-
SPECIALIZED OIL TANKER FAMILIARIZATION
SPECIALIZED CHEMICAL TANKER FAMILIARIZATION
ECDIS TRAINING A-II/1 A-
SPECIFIC ECDIS
SECURITY AWARENESS
SHIP SECURITY OFFICER TRAINING
BRIDGE/ENGINE TEAM AND RESOURCE
SHIP HANDLING AND MANEUVERING SIMULATION
ICE NAVIGATION TRAINING
TANKER MANAGEMENT AND SELF-ASSESSMENT
RISK ASSESSMENT AND INCIDENT INVESTIGATION
SAFETY OFFICER TRAINING
OTHERS:

KNOWLEDGE OF ENGLISH*:
*All Officers must have good knowledge of English; Maritime English certification strongly preferred.
VETTING EXPERIENCE:
USA TRANSIT VISA
Capital Ship Management Corp. HRM / SECTION 2 / F-002
Issue Date : 01/06/2022
Revision: 00
Authorized by: DPA

SEAFARER’S RECORD APPLICATION FORM

PREVIOUS SEA SERVICE - MINIMUM LAST FIVE YEARS

COMPANY VESSEL RANK TYPE FLAG DWT ENGINE TYPE FROM TO REASON FOR SIGNING OFF

MASTER / OFFICER SUPPLEMENT

RANK APPLICANT’S SIGNATURE:
Actual sea service
TOTAL YEARS IN RANK
Calendar years
TOTAL YEARS WITH OPERATOR Actual sea service
Actual sea service
TOTAL YEARS ON THIS TYPE OF TANKER (as applicable)
Actual sea service
TOTAL YEARS ON ALL TYPES OF TANKERS (as applicable)
DATE:
TOTAL YEARS ON BULK CARRIERS (use 1 decimal i.e., 2.4 yrs)
(as applicable)
FOR CAPITAL SHIP MANAGEMENT CORP. CREW DEPT USE ONLY
PROPOSED BY MANNING OFFICE/AGENT: DATE REVIEWED & APPROVED FOR INITIAL PROCESSING: