CENTRUM MARINE CONSULTANCY

- People. Passion. Professionalism -

Passport Size Photo
EMPLOYMENT APPLICATION FORM

Personal Details

Date Available: DD/MM/YYYY Date Applied: DD/MM/YYYY Position Applied: (rank)

Surname (As per the Passport) Other Names: (As per the Passport)

Permanent Address (With ZIP/ Postal Code):

Home No: +94 Mobile No: +94

E-Mail:
Nationality: SRI LANKAN Date of Birth: DD/MM/YYYY City/Place of Birth:
Blood Group: Weight (kg): Height (cm): Age:
Boiler Suits Size: Safety shoe Size: Religion:

Family Details
Marital Status: (Y /N) Surname of Spouse: Other Names of Spouse:

Date of Birth of Spouse: Place of Birth of Spouse: No. of Children:

DD/MM/YYYY

Home Address of Spouse (If different from the permanent address)

Full Name of the Father:

Full Name of the Mother:

Emergency Contact
Full Name of Next of Kin:
Relationship: Address:

Home No: +94 Mobile No: +94

E- Mail:

FORMAT NO: MHR/F/01, ISSUE DATE:01/01/2023, ISSUE NO :01, REVISION NO:00, REVISION DATE:00.00.0000 Page 1 of 5
 ACADEMIC QUALIFICATION—PRE-SEA TRAINING
Type of Degree/ Course Name of From To Town/Place Remarks
Institute/College DD/MM/YYYY DD/MM/YYYY
Eg – Deck/Engine / Catering
Training

TRAVEL/IDENTITY DOCUMENTS
DOCUMENT ISSUED COUNTRY Number D.O.I D.O.E
DD/MM/YYYY DD/MM/YYYY
PASSPORT (All Country) Sri Lanka
Seaman Book Sri Lanka
Seaman Book Others - 1
Yellow Fever Vaccination N/A
US visa (Valid) RC1/D
Schengen Visa (Valid)
Maritime Crew Visa (MCV) Australia
OTHERS VISAS (Valid)
COVID 19 Vaccination – 01st Dose Name - N/A
COVID 19 Vaccination – 02nd Dose Name - N/A
COVID 19 Vaccination – 03rd Dose Name - N/A

CERTIFICATION (STCW & VALUE ADDED)

CERTIFICATE/COURSE ISSUED BY ISSUED Number D.O.I D.OE

(Institute) PLACE
DD/MM/YYYY DD/MM/YYYY
Certificate of Competency

GMDSS Certificate

COP Able Seafarer Deck/ Able Seafarer

Engine
COP Basic Training Certificate

Deck/ Engine Room Watch Keeping

Certificate

FORMAT NO: MHR/F/01, ISSUE DATE:01/01/2023, ISSUE NO :01, REVISION NO:00, REVISION DATE:00.00.0000 Page 2 of 5
 CERTIFICATE/COURSE ISSUED BY ISSUED Number D.O.I D.O.E
(Institute) PLACE DD/MM/YYYY DD/MM/YYYY
Prof. in Elementary First Aid
(EFA)
Prof. in Personal Survival Techniques. (PST)

Prof. in Personal Safety & Social Responsibility.

(PSSR)
Prof. in Fire Prevention & Fighting (FPFF)
Prof. in Medical First Aid (MFA)
Prof. in Advanced Fire Fighting (AFF)
Prof. in Survival Craft and Rescue Boat (PSC &
RB)
Prof. in Medical Care (MC)
Prof. in Ship Security Officer (SSO)
Prof.in Ship Security Training for Seafarers with
Designated Security Duties (SDSD)
Prof. in Ship Security Awareness (SSA)
Navigation Watch Keeping Simulator
Radar Simulator
Bridge /Engine Room Resources Management -
Management Level
Automatic Radar Plotting Aids.
Electronic Navigation System.
Radar Observation & Plotting.
Ship Handling & Maneuvering
Management Level
ECDIS Generic
ECDIS Type Specific (Please specify the types)
MLC Cook Certificate
ETO/ETR
Maritime English

Additional Information

FORMAT NO: MHR/F/01, ISSUE DATE:01/01/2023, ISSUE NO :01, REVISION NO:00, REVISION DATE:00.00.0000 Page 3 of 5
 Vessel Trading Area Experience (countries/ Routes) Sailing Experience with Other Nationalities (List of Nationalities)

- -
- -
- -
- -
- -
- -
- -
-

REFERENCES:
Name of Company Address Name of Person Title & Phone No.

Data Protection Declaration of Consent

I (Full Name……………………………..) holder of National Seaman book number - …………………. hereby confirm
that I have provided my curriculum vitae to obtain the Service from Centrum Marine Consultancy And give
my consent for the processing of my personnel data.

I do hereby certify that the above particulars are true and accurate to the best of my knowledge.

Name & Signature of Applicant. Date:

FORMAT NO: MHR/F/01, ISSUE DATE:01/01/2023, ISSUE NO :01, REVISION NO:00, REVISION DATE:00.00.0000 Page 4 of 5
 PREVIOUS SEA SERVICES:
(Data Commencing from Last Vessel Served. Please complete all the records)

Year of Vessel Engine Type GRT/ kW Period on Owner/ Operator Reason for
Vessel Name Flag Built Type* Type of Rank From To board Discharge*
/ IMO No. Crane dd/mm/yy dd/mm/yy
(Deck)

* All fields are mandatory

*Vessel Type - Bulk Carrier – BC / Multi-Purpose – MLP / Container – CON / TUG / General Cargo – GC / Passenger – PAS / RORO Carrier – ROR / Tanker -TAN
Other – Please specify

*Reason for Discharge - Contract Completed - CC / Medical Grounds – MG / Vessel Sold – VS / Other Reasons - OR (Please Specify in the remarks)
Remark

 Centrum Marine Consultancy Pvt Ltd does not charge any fees or other charges for seafarer recruitment or placement or for providing
employment to seafarers.

FORMAT NO: MHR/F/01, ISSUE DATE:01/01/2023, ISSUE NO :01, REVISION NO:00, REVISION DATE:00.00.0000 Page 5 of 5