6. A general application form

12. P

E

1. R

S

O

N

L

P

A

R

T

I

C

U

L

A

R

S

SURNAME:

First Name:

Middle Name:

Nationality

Date of Birth:

Place of Birth

3. Marital Status

Name of Spouse

Permanent Address

Local Address

Telephone No.

Nearest International Airport

Passport No.

Place of Issue

Date of Issue

Date of Expiry

Seaman’s Book No.

Place of Issue

Date of Issue

Date of Expiry

F

A

M

I

L

Y

Give particulars of your immediate family members and indicate your relationship with them.

Name

Relationship

Occupation

EMERGENCY

Next of Kin:

Address:

Relationship:

Telephone No.

Home:

Telephone No.

Office:

E

X

P

E

R

I

E

N

C

E

SUMMARY OF EXPERIENCE

Experience As

Bulkcarrier

Cont

G.C

Chem

Reef

Others

Master/CE

C/O, 1/E

2/0, 2/E

3/0, 3/E

Engineer Applicant

Navigating Applicant

Duration

Duration

B & w

Bulk Carrier

Sulzer

Ore Carrier

H.A.N.

Container

Semi Pielstick

Reefer

Tanker

Chemical

Reefer

Tanker

Chemical

EQUIPMENT WORKED WITH

ITT/Marconi/JRC

Experience with Inmarsat

Whether agreeable to work in a lower rank

YES / NO

Whether agreeable to join vessel trading in war zone

YES / NO

Signature : Date:

FOR OFFICIAL USE ONLY

Interview Date:

Interviewed by:

Result:

Fleet Personnel Department

Note:

Interviewer

Note:

11. L

I

C

E

N

C

E

NATIONAL LICENCE PARTICULARS

MOT

Grade

Cert. No

Date/Place of Issue

Validity

National Licence

Panamanian

Liberian

Bahamas

S. T. C. W. COURSES

Ref №

Date of Issue

C

0

U

R

S

E

S

Survival at Sea

First Aid Sea

Fire Fighting

Radar Observers

Crude Oil Washing/ I.G.S.

Tanker Safety

Dangerous Cargo Endorsement

Radar Simulator

Radio Telephone

A.R.P.A.

Chemical Endorsement

G.M.D.S.S.

Q

U

A

L

I

F

I

C

A

T

I

0

N

S

ADDITIONAL PROFESSIONAL QUALIFICATIONS (W0RKSHOP/NAUTICAI COLLEGE)

Establishment Name

Date Attended

Basic Academic Qualifications

Date Passed