COMPANY WORK FORM Form No. F.6.

2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD

DATE AVAILABLE:      

POSITION APPLIED FOR:      
FULL NAME:       ATTACH
SURNAME:      PHOTO
FIRST NAME:       HERE
MIDDLE NAME(S)      
PERSONAL DETAILS
DATE OF BIRTH       PLACE OF BIRTH NATIONALITY HEIGHT      

WEIGHT       HAIR COLOUR       EYE      

COLOUR
MARITAL STATUS       SPOUSE’S NAME       No. of      
Children
FATHER’S NAME       MOTHER’S NAME       NEXT OF      
KIN
HOME ADDRESS       TEL. No.      
(PERMANENT)
OTHER ADDRESS       TEL. No.      

E-MAIL:       SKYPE:       HOMEPORT:       Mob No.      

LICENCES / DOCUMENTS HELD

ITEM No. I S S U E D EXPIRING GRADE
DATE PLACE BY DATE
NATIONAL LICENCE                                    
STCW ENDORSEMENT                                    
MARSHALLS ISL. ENDORSEMENT                                    
LIBERIAN ENDORSEMENT                                    
OTHER LICENCE                                    
PASSPORT                                    
NATIONAL SEAMAN’S BOOK/CDC                                    
OTHER SEAMAN’S BOOK / CDC                                    
U.S.VISA                                    
YELLOW FEVER VACCINATION                                    
P.R.C. No. (Filipino Crew only)                                    
National data base of seafarers INDOS                                    
Certificate No. (Indian personnel only)
CERTIFICATES HELD
ITEM No. ISSUED EXPIRING ISSUED BY
BASIC SAFETY TRAINING (*IF ONE CERTIFICATE)                        
PERSONAL SAFETY & SOCIAL RESPONSIBILITIES*                        
PERSONAL SURVIVAL*                        
SURVIVAL CRAFT HANDLING*                        
FIRST AID AT SEA (ELEMENTARY LEVEL)*                        
PROFICIENCY IN SURV.CRAFT/ RESCUE BOAT (PSCRB)                        
ADVANCED / SHORE-BASED FIREFIGHTING                        
PETROLEUM TKR SAFETY – BASIC/ GEN OIL TKR FAM.                        
MEDICAL FIRST AID                        
SHIP MASTERS MEDICARE/ADVANCED MEFA                        
PETROLEUM TKR SAFETY – ADVANCED/SPECIALISED                        
COW / IGS                        
DANGEROUS CARGO ENDORSEMENT - OIL                        
CHEMICAL TANKER SAFETY                        
LIQUIFIED GAS FAMILIARISATION                        
LIQUIFIED GAS SPECIALISED/ADVANCED COURSE                        
DANGEROUS CARGO ENDORSEMENT - LIQUIFIED GAS                        
LICOS (FOR LIQUIFIED GAS – PLS SPECIFY)                        
LIQUIFIED GAS-SPECIFIC FIRE FIGHTING – PLS SPECIFY                        
SIGTTO                        
STCW ENDORSEMENT                        
ARPA                        
R.O.C. / RANSCO / RADAR SIMULATOR                        
SATCOM                        
\\\

Rev. 3 dated 30/09/15

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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD

APPLICANTS NAME:      

_________________________________________________________

CERTIFICATES HELD (CONTINUED)

ITEM No. ISSUED EXPIRING ISSUED BY
GOC / GMDSS                        
ECDIS                        
SHIP MANOEUVERING/SHIP HANDLING SIMULATOR                        
SHIP SECURITY OFFICER                        
ISPS FAMILIARISATION                        
SHIPBOARD SAFETY OFFICER                        
ENGINE ROOM SIMULATOR                        
ENGINE ROOM RESOURCES MANAGEMENT                        
HUMAN RELATIONS                        
QUALITY AND SAFETY MANAGEMENT                        
RISK ASSESSMENT / RISK MANAGEMENT                        
MARINE ACCIDENT/INCIDENT INVESTIGATION                        
MANAGEMENT OF CHANGE                        
ENVIRONMENTAL COURSE / ISO 14001                        
MLC/LSC MARITIME LEADERSHIP COURSE                        
MARPOL I                        
MARPOL II                        
MARPOL VI                        
MARITIME ENGLISH                        
MLC 2006                        
BRIDGE TEAM MANAGEMENT                        
BRIDGE RESOURCES MANAGEMENT                        

RECORD OF PREVIOUS SERVICE (VERIFIED AGAINST SEAMAN’S BOOK ENTRIES)

COMPANY VESSEL’S TYPE/ DWT M/ENG’S BHP/ UMS RANK FROM TO MONTHS
NAME BUILT TYPE ( Y-
                                                           

                                                           
                                                           
                       
                                         
                                                           
                                                           
                                                           
                                                           
                                                           
                                                           
                                                           
     
     
                                                           
                                                           
                                                           
                                                           

Rev. 3 dated 30/09/15

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COMPANY WORK FORM Form No. F.6.2
Issue A Date 01/11/06
SEAFARERS’ APPLICATION FORM Authorised By MD
APPLICANT’S NAME: ___________________________________________________________________
ACTUAL TIME SERVED IN MONTHS
OBO / CHEM. / BULK
RANK LNG LPG CRUDE OIL PRODUCT CARRIER/
TANKER TANKER OTHER
MASTER OR CH. ENG.                              
C/OFF OR 1A/E                              
2/OFF OR 2A/E                              
3/OFF OR 3A/E                              
GAS/CARGO ENGINEER                              
CADET/JR.ENG                              
ETO / ELEC (PLS STATE)                              
PMN / FITTER                              
OTHER RANK                              

ALLOTMENT DETAILS
SURNAME      
NAME      
MIDDLE NAME      
DATE OF BIRTH      
RELATIONSHIP      
ADDRESS      
NAME OF BANK      
ACCOUNT No.      
SSS No. (Filipino crew only)      
TIN No. (Filipino crew only)      

WIFE & CHILDREN’S NAME S DOB POB PASSPORT NO. DATE OF ISSUED AT
      ISSUE EXPIRY
                                         
                                         
                                         
                                         
                                         
How long did you stay at your previous company?      
Wages on last vessel?      
Trade route of vessels?      
Who referred you to the company?      
Any relatives with the company?      
If yes, who?      
ANY OTHER INFORMATION ABOUT YOURSELF:      

UNION MEMBERSHIP NO.:       DATE :      

DOE:      
ALL APPLICANTS
DATE APPLICATION FILLED OUT      

SIGNATURE OF APPLICANT      

FULL NAME IN BLOCK CAPITALS      

Rev. 3 dated 30/09/15

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