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    02 - Application Form

    Uploaded by

    Mohamed El Sheikh
    This document is an application form requesting personal and professional details from applicants, including name, contact information, nationality, date of birth, passport photo, ranks and certifications held, sea experience, medical history, and references. It collects information over 7 sections addressing personal data, documents, family details, qualifications, sea experience, medical history, and general questions. Applicants are asked to provide details in uppercase letters and notified of various parts requiring additional information.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    02 - Application Form

    Uploaded by

    Mohamed El Sheikh
    21 views3 pages
    This document is an application form requesting personal and professional details from applicants, including name, contact information, nationality, date of birth, passport photo, ranks and certifications held, sea experience, medical history, and references. It collects information over 7 sections addressing personal data, documents, family details, qualifications, sea experience, medical history, and general questions. Applicants are asked to provide details in uppercase letters and notified of various parts requiring additional information.

    Original Description:

    Application

    Original Title

    02_Application form (4)

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    © © All Rights Reserved

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    This document is an application form requesting personal and professional details from applicants, including name, contact information, nationality, date of birth, passport photo, ranks and certifications held, sea experience, medical history, and references. It collects information over 7 sections addressing personal data, documents, family details, qualifications, sea experience, medical history, and general questions. Applicants are asked to provide details in uppercase letters and notified of various parts requiring additional information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views3 pages

    02 - Application Form

    Uploaded by

    Mohamed El Sheikh
    This document is an application form requesting personal and professional details from applicants, including name, contact information, nationality, date of birth, passport photo, ranks and certifications held, sea experience, medical history, and references. It collects information over 7 sections addressing personal data, documents, family details, qualifications, sea experience, medical history, and general questions. Applicants are asked to provide details in uppercase letters and notified of various parts requiring additional information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Application Form

    [ PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]

    Clear
    AFFIX YOUR RECENT PASSPORT
    SIZE PHOTOGRAPH HERE

    1. Personal Data
    Full Name Nationality Date of Birth Place / City of Birth

    Rank applied for: Last Salary: Ready From (date): Nearest Airport:
    Address/Contact Information:
    Permanent Address(full description):
    City: Country Email: Tel: Mobile:

    Sweater size: Boilersuit size: Shoe Size:


    How did you find and knows about us?
    Please Check Specify Details
    Friends
    Crewing agency
    members already in organization
    Internet
    Others
    [LANGUAGES / COMPUTER SKILLS [ E : excellent - G : good - A : average - P : poor
    LANGUAGE Spoken Written Read Software MS Office Maintenance
    COMPUTER
    English
    SKILLS

    Are you smoking / no smoking? Are you drinking alcohol / no drinking?

    Part 1, Notice if any?

    2. Personal ID / Documents
    Type of Document / ID Country of Issue No. Date of Issue Issued at (Place) Valid Until
    Passport
    Seaman’s Book
    medical
    Yellow fever

    Part 2, Notice if any?

    3. Nominee / Next of Kin & Family Details


    Address/Contact Information:
    Full Name of Nominee for compensation in case of fatality: Relationship
    City: Country Email: Tel: Mobile:

    Family Data:No of child


    Marital Status No of Childs

    Part 3, Notice if any?

    - Social Media Data ....Write Your Email Below if Any


    4. STCW & (amend.) Compliant Certificates / Courses and Other Qualifications: -
    Description of Cert / Course Country of Issue Number Date of Issue Date of Expiry Place of Issue Issuing Authority
    (A) Reg II / 1-5, III / 1-5 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag state endorsements) 1

    (B) GMDSS Certificates (including flag state endorsements)


    GMDSS (Main Issuing Authority)
    GMDSS (Flag State)
    1
    Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you
    (C) Basic/mandatory/recommended Certificates / Courses – (as applicable)

    Other Courses specified below if any:

    :Courses only for rank Cook's Training Certificate ( MLC, 2006

    Part 4, Notice if any?

    5. Sea Experience : (Start the listing below with the most 5 recent experience)
    Company Flag & Vessel Name Type (1) GRT DWT Main Engine (2) BHP Rank Date From Date To

    (1)
    Use only the abbreviations for vsl types as folllowing: general cargo (G.C)….. etc
    (2)
    Engineers to give make/model of engines, e.g. “MAN 14V52/55A” or “SULZER 5RTA58”
    Part 5, Notice if any?
    6. Medical History:
    All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed, the Company is entitled to refuse any reimbursement of
    medical costs, claim for treatment or for any other insured benefits.
    (A) Have you ever signed off a ship due to medical reasons?
    If yes, please provide following details (If space is insufficient, attach additional sheets) :
    Blood Type:

    Name of vessel Date of occurrence Place of occurrence

    Brief description of illness/injury/accident

    (B) Have you undergone any operation in the past?


    Details of operation Date Period of disability Present condition

    (C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
    Details of illness / accident Date Therapy/Treatment

    (D) Please give details of any health or disability problem


    Details:

    Part 6, Notice if any?

    7. General
    (A) Have you been the subject of a court of enquiry or involved in a maritime accident?

    (B) Give details below of two recent employers who we may contact for references:
    Reference 1 Reference 2
    Name of Company
    Name of person to contact
    Address
    Country
    Telephone

    Part 7, Notice if any?

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