SEAFARER’S APPLICATION

FORM

Please refer to QP3.0, section 4.10.16

Please complete dates as dd/mm/yyyy

Name of Manning Agency/Supplier:
Rank: / For the Vessel:
Date of Availability: / Date of Last Disembarkation:
Reason for Last Disembarkation:

Personal Details

Full Name (Family, Given, Middle):
Date of Birth: / Place & Country of Birth:
Nationality: / Passport No:
Passport Issue Place & Date: / Passport Expiry Date:
Seaman’s Book No:
Seaman’s Book Issue Place & Date: / Seaman’s Book Expiry:
Marital Status: / No of Children: / Nearest Airport:
Height (m): / Weight (Kg): / BMI:

Address & Contact Details

Home Address (including City, State/Province/Country):
Telephone No (Landline, include Country & City Code): / +
Telephone No (Mobile/Cell include Country Code): / +
Email Address:

Family/Next of Kin Details

Full Name (Family, Given, Middle) / Relationship / Date of Birth / Telephone/Contact No
+
+
+
+
+
+

Details of Education/Academic Qualifications

Name of School or College attended / Location / From / To / Qualification Received
Reference / Seafarer’s Application Form / Form No. / MHRD-5 / Original: Manning Agent
Effective Date / 01 January 2017 / Page / 1 of 3

SEA SERVICE RECORD

IMPORTANT - Please state most recent sea service first

Vessel Name / Flag / Rank / Type / DWT / Engine Make / Engine
Model / BHP/KW / UMS (Y/N) / From
dd/mm/yyyy / To
dd/mm/yyyy / Reason for Disembarkation / Owner
Manager

Required for Engine Room Staff Only

For Bulk Carrier Type, please state: MBLK for Mini, HBLK for Handy, LOGB for Log Carrier, HMBC for Handymax, SMBC for Supramax, PBLK for Panamax , KSMX for Kamsarmax, CBLK for Capesize, VLOC for Very Large Ore CarrierWOOD for Wood Chip Carrier.

For Tankers, please state: LPGP for Pressurised, LPGS for Semi-Refrigerated, LPGR for Fully Refrigerated, LPGE for Ethylene, LPCH for LPG/Chemical, CHET for Chemical, PROT for Product Tanker, MRP for Medium Range Product, LRP for Long Range Product, AOIL for Aframax, SOIL for Suezmax, VLCC for Very Large Crude Carrier & ULCC for Ultra Large Crude Carrier.

Remarks (as per QP4.0, section 4.3.22 & 4.3.23)
Reference / Seafarer’s Application Form / Form No. / MHRD-5 / Original: Manning Agent
Effective Date / 01 January 2017 / Page / 1 of 3

Visa Details

Type / Issued / Expires / Place of Issue
USA visa
Australian Maritime Crew Visa (MCV)

National Licence/Certificate of Competency/Endorsement Details

Grade / Number / Date of Issue / Date of Expiry / Issuing Country

FlagState Licence/Certificate of Competency/Endorsement Details

Grade / Number / Date of Issue / Date of Expiry / Issuing Country

Details of Training/Upgrading Courses & Certificates

Course Name / Cert Number / Date of Issue / Date of Expiry / Issued By
Reference / Seafarer’s Application Form / Form No. / MHRD-5 / Original: Manning Agent
Effective Date / 01 January 2017 / Page / 1 of 3