CMA SHIPS Singapore OPERATIONS MANUAL SECTION 3
Ref: Crew/Form/01a Version: 01/07/2015 PAGE 1 of 1
TITLE: APPLICATION FORM
APPLICATION FORM ATTACH
RECENT
PHOTO
CMA Ships Myanmar
84 Pan Hlaing Street, Sanchaung Township
11111 Yangon, The Republic of the Union of Myanmar
Position applied for:
Type of Vessel:
Availabibity Date:
Are you responding to a media advertisement? (YES/NO)
If YES, please state which one
Are you applying upon personal or professional recommendation? (YES/NO)
If YES, please state who
Surname: First name:
Other names:
Nationality:
Known as
Male
Place of Birth: Date of Birth: Age:
Female
Passport
Number Place of Issue Date of Issue Date of Expiry Issuing Authority
Visas
Type Number Place of Issue Date of Issue Date of Expiry
C1/D (USA)
C1 (USA)
D (USA)
Australia Entry visa
MCV (Australia)
Schengen
Education Background
School / College From To Highest Qualification attained
Personal details
Full Address:
Postal Code: Country:
E-mail: Skype ID:
Mobile Phone:
Home Tel No.:
Domestic Airport: International Airport:
Marital Status:
Full name of
Relationship:
Next of Kin:
Address of Next of Kin
Phone
if different from above
if
different from above
Dependents
Name Date of birth Age Gender Relationship
Person to contact in case of emergency
Name: Relationship:
Address:
Phone Number: Mobile Number:
National Seaman's Book
Number Place of Issue Date of Issue Date of Expiry Issuing Authority
National Certificate of Competency (COC)- Licences
Issuing
Grade Number Date of Issue Date of Expiry Place of Issue Date Revalidated Date of Expiry
Authority
National GMDSS & Endorsement
Issuing Authority Number Date of Issue Date of Expiry Place of Issue
Medical Fitness Certificate
Type Date of Issue Date of Expiry
Yellow Fever Vaccination
Date of Issue Date of Expiry
Foreign languages other than English
Language Level:
Beginner Intermediate Advanced
Medical History
Have you ever signed off froma ship due to medical reasons? Yes / No If yes give details
Name of vessel Date of Occurrence
Brief description of
Illness or Injury
Other personal details
Height: Weight: Colour of Hair:
Colour of eyes: Safety shoes size: Boiler suit size:
Uniform Shirt size: Uniform Trousers size:
Details of other Marine courses
Type of Marine Course IMO Model Course Reference- Regulation Number Date of Issue Date of Expiry
STCW Reg. A-VI/1-1 to A-VI/1-4
Basic Training 1.19 - 1.20 1.13 - 1.21
Personal Survival STCW Reg. A-VI/1-1
1.19
Techniques
BASIC TRAINING
STCW Reg A-VI/1-2
Basic Fire Fighting 1.20
STCW Reg A-VI/1-3
Elementary First Aid 1.13
Personal Safety & Social STCW Reg A-VI/1-4
Responsibilities (Human 1.21
Relationship)
STCW Reg A-VI/2 par 1.3
Proficiency in survival craft & Rescue Boats 1.23
STCW Reg A-VI/3
Advanced Fire Fighting 2.03
STCW Reg A-VI/4-1
Medical First Aid 1.14
STCW Reg A-VI/4-2 par 2
Medical Care 1.15
STCW Reg II/2
ROP 1.08
STCW Reg II/1
ARPA / NCC 1.07
Radar Simulator
STCW Reg II/1 par.2.5
ECDIS 1.27
US 49 CFR 172.700-172.204
HAZ MAT
STCW Reg II/1
Ship simulator bridge teamwork 1.22
BTM / ETM
STCW Reg VI/5 / ISPS Code
Ship Security Officer (SSO)
BASSnet
STCW Reg II/1 & II/2
Ship handling & manoeuvring
STCW Reg VIII/2 US33CFR 157.415
Bridge resource management
Loading software (name it)
Large Vessel Handling Simulator / Engine CMA CGM
Room Simulator
Indos Number
Upgradation Course
Revalidation Course for renewal of CoC
High Voltage Training
Reefer Training
Engine Maker’s Training
Crane Manufactures training
ISPS code
Vessel security training course
IMO Assembly Res A741(18)
Ship Safety Officer
UK MCA
ISF Marlins English test
Flag State Documents
Document Grade Number Place of Issue Date of Issue Date Expiry
Malta:
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Employment history (at least the last 10 years)
Vessel IMO Number Company Manning Agent Trading Area Vessel Type Flag (DWT or TEU) Year Main Engine Position Sign on date Sign off date Total Reason for Leaving
* ** DWT xxxxx
TEU xxxxx
Built mm/dd
***
Make Type KW
* or industry sector if ashore
** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off
*** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract
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Summary of Experiences (in number of years)
Years as/ on Container Tanker Bulk Carrier Ro-Ro Others (Please state)
Master - C/E
C/O - 2/E
2/O - 3/E
3/O - 4/E
E/O
Total
SEMT
Years as/ on Sulzer RTA Sulzer RND MAN-ME MAN-MC Steam Turbine Others
Pielstick
C/E
2/E
3/E
4/E
E/O
Total
References
Do you have any objection if we will contact your last employers for reference? Yes/No
If YES please specify why:
If NO please specify why:
Please give the name and address of your current or immediate past employer
Name of company
Name of person to contact
Address
Tel number
Please list two contactable referees or past employers
Name of company
Name of person to contact
Address
Tel number
Name of company
Name of person to contact
Address
Tel number
Bank details
Bank name: Sort code:
Swift name IBAN
Branch name
number:
Address:
Account name/ Title Account number:
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief; further, that no Certificate
of Competency or License issued to me has ever been revoked or suspended. I also certify that my medical history contained above is true and any false
statement or undisclosed material information about past illness or injury will disqualify me from any employment benefits and claims.
Date________________ Signature_______________________
* The company may contact my previous employer for references.
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