Seafarer's Application Form

Present Rank:
 Rank Applied For:
 Application
Full Name:
 Date of Birth:
Place of Birth:
 Nationality:
Address:
Phone:
 Email:
Next of kin / Relationship / Address:
Height:
 Weight:
 Union Member:
Marital Status:
 Number of Children:
 Suit Size:
Shoe Size:
 Last Medical Exam Date:
 Yellow Fever Vaccination Date:
U.S Visa Expiry Date:
 Date of Availability:

Documents

DocumentIssue DateExpire DateCountry of IssueGrade
Diploma National
Diploma Other
Seaman Book National
Seaman Book Other
Passport
Seafarer Employment Form
Certificate of Fitness

Certificates

CERTIFICATES REG. EXPIRE CERTIFICATES REG. EXPIRE
Endorsement Radar & ARPA Simulator (Operational Level)
Continue Proficiency Hazardous material
Watch keeping Certificate GMDSS
Personal Survival Techniques SSO Certificate
Fire Prevention & Fire Fighting Risk Assessment Certificate
Elementary First Aid ECDIS Generic & Specific Training
Personal Safety & Social Responsibility Certificate of qualification as Cook
Proficiency in Survival Craft Ship Specific Familiarization
Advanced Fire Fighting Security Familiarization
Medical First Aid Security Awareness / Security Training
Medical Care Training Record Book
Radar & ARPA (management level) Other

Previous Sea Experience

Experience 1
Type
Vessel’s Name
ManagersRank
D.W.Eng. Type / B.H.P
FromTo
Reason for Sign Off
Experience 2
Type
Vessel’s Name
ManagersRank
D.W.Eng. Type / B.H.P
FromTo
Reason for Sign Off
Experience 3
Type
Vessel’s Name
ManagersRank
D.W.Eng. Type / B.H.P
FromTo
Reason for Sign Off
Experience 4
Type
Vessel’s Name
ManagersRank
D.W.Eng. Type / B.H.P
FromTo
Reason for Sign Off
Experience 5
Type
Vessel’s Name
ManagersRank
D.W.Eng. Type / B.H.P
FromTo
Reason for Sign Off
Accepted For M/V:
 Interviewed By:
 Date:
Crew Manager:
 Date:
Approved By:
 Date: