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
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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-
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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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