Ref: / Ship Personnel Management / Pages: / 1/4
Form No. & Title: / (03-01-O) Crew Application Form / Date / 01.08. 12
1.Instructions
1.1This application form has been designed to provide us with the basic information for easy processing of your application for employment with us. It also serves as our personnel record should you be employed.1.2It is essential for you and helpful to the interviewer that the form is neatly, carefully and correctly filled. Please use BLOCK CAPITALS.
1.3All parts are to be completed and where not applicable, state N.A.
1.4If space is not sufficient, please attached an addendum.
1.5All relevant certificates, discharge book, passport, testimonials, references of previous employment, if any to be attached. / Recent
Photo
Pls provide 6 pcs
2.Position Applied For
2.1 Application for position of:2.2 Source of application: newspaper / union / association / personal contact*.
* Delete whichever is not applicable
3.Personal Particulars
3.1 First Name / 3.2. Middle Name / 3.3 Last Name3.4 Address & Telephone no.
3.5 Date of birth / age / 3.6 Place of Birth / 3.7 Nationality / 3.8 Marital Status
3.9 Passport No. / 3.10 Date of issue / 3.11 Date of Expiry / 3.12 Office of issue
3.13 Discharge Book No / 3.14 Date of issue / 3.15 Date 6f Expiry / 3.16 Place of Issue
4.Next-Of-Kin
4.1 Full Name : / 4.2 Relationship:4.3 Address, if different from above: / 4.4 Telephone:
5.Certificate of Competency / Endorsements
5.1 Grade: / 5.2 Grade / 5.3 Number: / 5.3 Date & Place of issue:Certificate of Competency
STCW 95 Endorsement
Tanker Endorsement (Oil/Chemical/Gas)
Certificate Of Equivalence (CEC)
6.STCW Training Certificate
6.1 Certificate: / DeckClass / Eng
Class / 6.2 Certificate
Number / 6.3 Date of Issue / 6.4Issuing Authority
1. Advanced Oil Tanker Familiarization / 1, 2 / 1, 2
2. Medical Care onboard / First Aid at
Sea / 1, 2
3. Navigation Control Course / 1, 2
4. Advanced / Basic Fire-fighting / 1, 2
3, 4, 5 / 3, 4
5. GMDSS GOC / 1, 2,
3, 4, 5
6. Proficiency in Survival Craft
& Rescue Boat */ Personnel Survival
Technique / 1, 2,
3, 4, 5 / 3, 4
7. Basic Safety Training * / 1, 2
3, 4, 5 / 1, 2,
3, 4,
8. Electronic Navigational Course (Radar & ARPA) / 3, 4, 5
9. Tanker Familiarization *
(Oil/Chemical/Gas) / 3, 4, 5
*Deck and Engine Ratings are required to produce these Certificates in their Application
7.Other Training
7.1 Type of training: / 7.2 Certificate No: / 7.3 Period:1. BTM
2. SHIP HANDLING
3. ISM Code
4. SSO & Others
8.General Education
8.1 Please give details of your full-time schooling only. Name of InstitutionFrom / To / Level
9.Language Proficiency
9.1 Language / 9.2 Spoken* / 9.3 Written*English
Indonesian
Korean
Others
* If Fluent mark ‘A’, if working knowledge mark ‘B’
10.Expected Salary
11.Previous Employment (last 5 years)
11.1 / Name of ex-Employer / 11.2Type / 11.3 Trade+ / 11.4 Size GRT/BHP/KW
++ / 11.5 Rank / 11.6 Period of
Service
Name of Vessel / Ship / Eng / From / To
12.Summary Of Experience
12.1 Officer / Years / 12.2 Engineer / Years / 12.3 Rank / YearTanker / Hanshin
Bulk Carrier / Yanmar
General Cargo / Akasaka
Container / Daihatsu
Supply Boat / Mitsubishi
Others / Others
13.Medical History
13.1 Please state with dates of any serious illness, operations or disability:13.2 Do you suffer from any physical impairment? If YES, give details.
14.Criminal Record
14.1 Have you ever been convicted in a court of law in any country? If YES, give details.15.Declaration to be signed by the Applicant
15.1I hereby declare that the information contained in this form is true and correct to the best of my knowledge and belief, and that I have withheld nothing that would affect this application. I also understand that if employed, my services may be terminated if any of the information given above is found to be false.15.2I understand that a strict medical examination is a condition precedent to selection for appointment and I express my willingness to be so examined and to furnish the consulting physician with full details of my previous medical history.
Signature of Applicant: ______Date: ______
+ For Home Trade state HT, for Foreign Going state FG, for Highsea Bunkering state HB, for Special Limit state SL
++ For Deck state GRT, for Engine state kW/BHP
For Office Use Only
16.Application Provisional Category
16.1 Suitable / Unsuitable / comments if any:17. Comments if any:
17.1 Comments :18. Appointment
18 .1 Rank: / 18.2 Department:18.3 Date to Join: / 18.4 Port Join:
19. Remuneration
19.1 Basic Wage: / 19.2 Fixed Overtime:19.3 Bonus: / 19.4 Leave Pay:
19.5 Victual: / 19.6 Other Fringe Allowance:
20. Probation
20.1 Probation Period: / 20.2 Expiry Date:20.3 Confirmed: / 20.4 Recommended by:
20.5 Extended: / 20.6 Date:
20.7 Wage Adjustment After Probation:
21.Approval / Acceptance
21.1 Interviewed By: / 21.2 Date:21.3 Approved By: / 21.4 Date:
SQST/ISM/SMSM/Forms 03