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Reg.

No:__________
Candidate Employment Application Form
Document No. Issued Place Valid Until
Passport: Country
Seamans Book (CDC): National
Seamans Book (CDC): Other
Indicate type of valid visa USA C1 Yes No valid until D Yes No Valid Till:

Family Data:
Relationship First Name Last Name Date of Birth Passport No. Issued Place Valid Until
Spouse
Child M
f
Child M
f
Photo
First Name

Middle Name Last Name/Surname
Nationality

Date of Birth Place of Birth
Post applied for Willing to accept lower rank?
Yes No
Available From:
Permanent Address: Present/Temporary Address:
Postal Code: Tel: Postal Code: Tel:
Nearest Airport: Nearest Airport:
Name of Nominee for compensation in case of fatality: Relationship:
Address:
City: Post Code: Tel:
Child M
f
Child M
f
Child M
f
Indicate type of valid visa (1) USA Canada Brazil UK Others
CERTIFICATES/COURSES:
Issuing Authority: Grade (1) Certifcate
Number
Date Issued Place Issued Valid until
National (Country )
Others: PANAMA
(1) Specify whether: Deck Class 1= Master FG Engine Class 1= 1
st
CLASS (M), (S), (M+S) R/O RT only
2= 1
st
Mate FG 2= 2
nd
CLASS (M), (S), (M+S)
3= 2
nd
Mate FG 3 =
4= 4 = 4 Class4 (M), (S), (M+S)
Dangerous Cargo Certifcation:
Endorsement on NATIONAL Certifcate Number Date Issued Place Issued Valid Until
Petroleum
Liquifed Gas
Liquid Chemicals
Endorsement/Certifcate obtained (Liberian,

qualifying as (Capacity) (2)
Number Date Issued Place Issued Valid Until
Petroleum
Liquifed Gas
Liquid Chemicals
Crude Oil Washing
Courses
Conducted
by (Institution)
Certifca
te Number
Date
Issued
Place
Issued
Valid
Until
C.O.W.
I.G.S.
Tanker-Safety-
Petroleum
Tanker-Safety-
Chemical
Tanker-Safety-
Liquid Gas
Tanker-
Familiarisation-
Petroleum
Tanker-
Familiarisation-Chemical
Tanker-
Familiarisation-Liquid
Gas
Other Certifcates held and courses attended:
Course/Certifcate Certifca
te Number
Date
Issued
Place
Issued
Valid
Until
Personal Survival Techniques
Profciency in Survival Craft & Rescue
Boat
Elementary First Aid / Medical First Aid
Ship Masters Medicare
Fire Prevention & Fire Fighting
Fire Fighting Advanced
Personal Safety & Social Responsibility
Radar Observer
Radar Simulator
A.R.P.A.


Course/Certifcate
Number Date
Issued
Place
Issued
Valid
Until
Ship Manoeuvring Simulator
Engine Room Simulator
Liquid Cargo Handling Simulator
Restricted R/T
G.M.D.S.S.
Revalidation
INDOS
Others :
Watch keeping Certifcate: (for ratings only) Include Flag state Qualifcation
Certifcate to work as (e.g.
AB/Motorman)
Certifca
te Number
Date
Issued
Place
Issued
Valid
Until
Watch Keeping
SEA EXPERIENCE: (Last 5 years) (Recent experience on top )
C
ompany
Vess
el
T
ype
Main
Engine (1)
B
HP
R
ank
D
ate From
d
d/mm/yy
D
ate To
dd
/mm/yy
(1) Engineers to give make/model of engines, e.g. MAN 14V52/55A or SULZER 5RTA58
For Ofce Use ONLY ASSESSEMENT OF CANDIDATE DURING INTERVIEW
Appearance
(on a scale of 1-10)
Attitude
(on a scale of 1-10)
English
(on a scale of 1-10)
Scale / 10 / 10 / 10
Remarks
_________________________________ ____________________
Name and Signature of Interviewer Date and place
MEDICAL HISTORY
It is MANDATORY that all illnesses other than minor afictions should be stated. The Company is entitled to refuse any claim for
treatment, cost or any other insured benefts if a complete statement of all previous illnesses has not been given.
(A) Have you ever signed of a ship due to medical reasons? Yes No
If yes, please provide following details:
Name of vessel Date of occurrence Place of occurrence
Brief description of illness/injury/accident
(B) have you undergone any operation in the past? Yes No
If yes, please provide following details:
Details of operation
Date Period of
disability
Present
condition
(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
Details of illness Date Therapy/Treatment
(D) Please give details of any health or disability problem
Details of illness
BANK/PENSION SCHEME/MEMBERSHIP DETAILS:
Bank Name MUI/NUSI
Address Membership No.
Account Name
Account No.
Sort Code
GENERAL
(A) Have you ever been denied a foreign visa? Yes No
If yes, state which country and reason (if known)
(B) Have you been the subject of a court of enquiry or involved in a maritime accident? Yes No
If yes, please attach details
(C) References
Please give references from two recent employers whom we may contact for references
Reference 1 Reference 2
Name of Company
Name of person to contact
Address
Country
Telephone
I hereby declare that the above, including Medical History, is true.
Place: __ Date: ______________ Signature: ________________
_________________________________ _____________________
Manning representative Date
Signature and Stamp

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