QATAR SHIPPING COMPANY Q.S.
C
Application For Employment
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 1 of 5
Position Applied For: ________________________________
Availability Date: ____________________________________
Photograph
Date Of application: _________________________________
Please Use Black Ball Point Pen & Capital Letters As Far As Possible
Surname
Middle Name
First Name
Nationality
Date of Birth
Place of Birth
Permanent Address:
Present Address:
Post code:
Phone: +
Post Code:
Phone: +
Email:
Date of
Issue
Mobile No:
Date of
Expiry
ECNR
Blank Pages
Passport No
Yes/No
Yes/No
U.S. VISA
MUI/Union Membership
No:
Seamans Book
(CDC)
Indian
Liberian
Panamanian
Marshal Islands
IOM
Bermuda
INDOS No :
Others
Number
Place of
Issue
Date of Issue
Place of
Issue
Expiry
Date
Remark
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 2 of 5
QATAR SHIPPING COMPANY Q.S.C
Application For Employment
License
Grade
Indian
U.K.
Singapore
Liberian
Panamanian
Marshal Islands
IOM
Bermuda
Others
Dangerous Cargo
Endorsements
Oil
Chemical
Liquefied Gas
Number
Grade/ Level
Date of
Issue
Number
Place of
Issue
Date of
Issue
Date of
Expiry
Place of
Issue
D.O.E
Civil Status: Single/ Married/ Separated/ Divorced/ Widowed
Full Name of Next of Kin:
Relationship:
Address of
Next of Kin:
PhoneWeight :
Height : ___________mts ____________ cm
Boiler Suit Size
Family
Data
Wife
Child
M/F
Child
M/F
Child
M/F
* Tick
Valid
________________ Kg
Shoe Size
Name
D.O.B
Passport D.O.I
No
Place of
Issue
Visa
USA
UK
Brazil
Australia
D.O.E
ECNR
(Yes/No)
QATAR SHIPPING COMPANY Q.S.C
Application For Employment
Details of Courses &
Certificates
Advanced / Basic Fire Fighting
Proficiency in Survival Craft /
Rescue Boat / PST
Elementary / Medical First Aid
/Medicare
Personal Survival & Social
Responsibility (PSSR)
Radar Observer / ARPA
Radar Simulator (RANSCO) /
ENS
Ship Handling Simulator
LCHS/Gas Cargo Simulator
GMDSS / MCC
Petroleum Tanker Safety
(STPOTO)
Chemical Tanker Safety
(CHEMCO)
Gas Tanker Safety (GASCO)
Oil Tanker Familiarisation
(OTFC)
Chemical Tanker Familiarisation
(CTFC)
Gas Familiarisation (GTFC)
Ship Simulator
Engine Room Simulator
Hazmat Course
Bridge Team Management
Engine Resource Management
Revalidation Course
FRAMO
NOR CONTROL
PMS SYSTEMS
Risk Management/Loss
Prevention
OPA 90
Commercial Knowledge
Courses
Ship Security Officers Course
ISM Course
ISO Course (9000,14000,18000)
Yellow Fever
Number
Date of
Issue
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 3 of 5
Date of
Expiry
Issued
by
QATAR SHIPPING COMPANY Q.S.C
Application For Employment
Educational Qualification
Name of Institute / College
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 4 of 5
From
To
Type of Degree
Pre Sea Training Apprentice ship
Name of Institute / College From
To
Type of Degree
Reference Checks( For Office use only)
Name of the company
Address
Name of Person /Company
1.
2.
Title
Yes
No
Phone No.
I hereby affirm that all this 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 Licence issued to me has ever been Revoked or Suspended. I also
certify that any false statement or undisclosed Material information about the past will
disqualify me from any employment benefits and claims.
Date___________
Rank___________ Signature of Applicant ____________
Note: All pages to be sent by agents as Fax or Email attachments
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 5 of 5
QATAR SHIPPING COMPANY Q.S.C
Application For Employment
Previous Sea Service (Date Commencing from Last Vessel Until First Vessel)
Sr.No. Name of Owners
/ Manager
Name of
Vessel
Type
1
2
3
4
5
6
7
8
9
10
11
12
Note: Please use Extra Pages As Applicable.
DWT
BHP
Engine type
UMS
Y/N
Rank
From
To
Total
MM/DD
Reason
for
S/OFF
