SeaMate Lanka (Private) Ltd

Fishery Harbour, Modara, Moratuwa. Sri Lanka. Tel: +94112657448, +94382232074 Fax: +94112657628

Email: Website: www.seamatelanka.com

Application

Personal Data

Position Applied for / Willing to accept Lower Rank Yes
No / Available From (DD/MM/YYYY)

(As per the Passport)

Surname / Other Name
Nationality / Date of Birth (DD/MM/YYYY) / Place of Birth
Sri Lankan
Marital Status / Gender Male
Female / Religion
Height (CM) / Weight (KG) / Blood Group / Overall Size / Safety Shoes Size
Permanent Address / Present Address
Home Tel / Home Tel
Mobile No / Mobile No
Fax / Fax
Email / Email
Full Name of Next of Skin / Relation Ship / Gender Male

Female / Nationality
Wife / Sri Lankan
Address / Home Tel / Mobile No / Email

Pre-Sea Training

Training Institute / Degree/Diploma/Certificate / Certificate Number / From / To

CDC/Passport/Documents/Visa

Type of Document / Country of Issue / Number / Place of Issue / Date of Issue
(DD/MM/YYYY) / Valid Until
(DD/MM/YYYY)
Seaman book (CDC)
Passport
National ID
US Visa
Yellow Fever
Panama
Bahama
Liberia

Marshall Islands

Certificate of Competency & Watch Keeping Certificate

Qualifications / Type/Grade/Class of License/Country of Issue / Number / Date of Issue / Date of Expiry / Issuing Authority
Certificate of Competency
Watch Keeping Certificate
Endorsement - Oil
Endorsement - Chemical
Endorsement - Gas
Endorsement – Other
Special Tanker Safety (Oil)
Special Tanker Safety (Chemical)
Special Tanker Safety (Gas)

STCW Courses/ Other Recommended Certificates

Details of Courses & Certificates / Number / Date of Issue / Date of Expiry / Issued by
Basic Fire Fighting
Elementary First Aid
Personal Survival Technique
Personal Safety & Social Responsibility
PELS/PELO
Advanced Fire Fighting
Proficiency in Survival Craft including Rescue Boats other than Fast Rescue Boat
Medical First Aid
Medicare
Radar Observer
ARPA
Radar Simulator
GMDSS
ECDIS
Ship Handling Simulator
LCHS
Tanker Familiarization
Oil Tanker Familiarization
Chemical Tanker Familiarization
Gas Tanker Familiarization
Petroleum Tanker Safety
Chemical Tanker Safety
Gas Tanker Safety
Engine Room Simulator

Hazmat Course

Bridge Team Management

Bridge Resource Management
Bridge Team /Resource Management
SSO /SSA
Revalidation course

Previous Sea Service (Commencing from Last Vessel) All Fields are Mandatory

Name of Company / Name of Vessel / Flag / Type / GRT / BHP / DWT / UMS
Y / N / Rank / From
(dd/mm/yyyy) / To
(dd/mm/yyyy) / Total Sea Service
(dd/mm/yyyy) / Reason for Sign-Off
Y / M / D

References (Please give two referees/companies whom we can ask about your seagoing experience)

Name / Company / Designation / Telephone / Contact. No
Declaration
I certify that the details given by me in filling up this form are true, complete, and correct to best of my knowledge and belief. I understand that any misrepresentation or material omission made in this application form or other documents submitted to Seamate Lanka pvt Ltd may renders me liable for termination or dismissal.
Date: Signature of Applicant