Personal Details

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1.1 Personal Details

Title

Surname

Other Name

Full Name

Nationality

Date of Birth (YYYY-DD-MM)

Place/ City of Birth

Marital Status

Gender

Religion

Rank Applied*

Willing to Accept Lower Rank

Available Date (YYYY-DD-MM)

1.2 Contact Details

Primary/Permanent Address

City

Country

Home Tel

Mobile No*

Fax

Email

1.3 Measurements

Collar Size (cm)

Chest Size (cm)

Waist Size (cm)

Inside Leg Size (cm)

Cap Size (cm)

Overall Size

Safety Shoe Size

Height (cm)

Weight (Kg)

BMI: weight (kg) / [height (m)]2

Personal ID/Documents/Visa

Country of Issue

Number*

Date of Issue (YYYY-DD-MM)

Issued at (Place)

Valid Until (YYYY-DD-MM)

Country of Issue

Number*

Date of Issue (YYYY-DD-MM)

Issued at (Place)

Valid Until (YYYY-DD-MM)

Country of Issue

Number

Date of Issue (YYYY-DD-MM)

Issued at (Place)

Valid Until (YYYY-DD-MM)

Country of Issue

Number

Date of Issue (YYYY-DD-MM)

Issued at (Place)

Valid Until (YYYY-DD-MM)

Lifetime

Valid Date

Country of Issue

Number

Date of Issue (YYYY-DD-MM)

Issued at (Place)

Valid Until (YYYY-DD-MM)

Nominee/Next of Kin and Family Details

3.1 Nominee/Next of Kin Details

Full Name of Next of kin

Relationship

Gender

Male

Female

Address

City

Country

Nationality

E-mail

Tel

Mobile

* Select from: Spouse / Child / Grand Parent / Other Relative (Please Specify)

3.2 Family Details

First Name

Last Name

Date of Birth (YYYY-DD-MM)

Passport No.

Issued Date (YYYY-DD-MM)

Place of Issue

Valid Until (YYYY-DD-MM)

First Name

Last Name

Date of Birth (YYYY-DD-MM)

Passport No.

Issued Date (YYYY-DD-MM)

Place of Issue

Valid Until (YYYY-DD-MM)

First Name

Last Name

Date of Birth (YYYY-DD-MM)

Passport No.

Issued Date (YYYY-DD-MM)

Place of Issue

Valid Until (YYYY-DD-MM)

First Child

First Name

Last Name

Gender

Male

Female

Date of Birth (YYYY-DD-MM)

Passport No.

Issued Date (YYYY-DD-MM)

Place of Issue

Valid Until (YYYY-DD-MM)

STCW – Compliant Certificates/Courses and Other Qualifications

4.1 Pre-Sea Training (Deck Rating/ Engine Rating/ Marine Skilled Craftsman)

Certificate No.

Qualification

Training Institute

From (YYYY-DD-MM)

To (YYYY-DD-MM)

4.2 License

*Enter actual description given in the Certificate of Competency / Watch keeping Certificate held by you

Qualification

Type/Grade/Class Of License

Country Of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Qualification

Type/Grade/Class Of License

Country Of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Qualifications

Type/Grade/Class of License

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Qualifications

Type/Grade/Class of License

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

4.3 STCW Certificates

Description of Certificate/Course

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Description of Certificate/Course

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Description of Certificate/Course

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Description of Certificate/Course

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

4.4 Other Mandatory / Recommended Certificates / Courses – (as applicable)

Description of Cert/Course

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Description of Cert/Course

Country of Issue

Number

Date Of Issue (YYYY-DD-MM)

Date Of Expiry (YYYY-DD-MM)

Issuing Authority

Sea Experience

Please enter at least last 5 years experience to the listing below with the most recent experience in the top most row

All Fields are Mandatory

Company / Manning Agent

Flag

Vessel Name

IMO No.

Vessel Type

TEU

GRT

DWT

Engine Make/ Model

BHP

Rank

Date from (YYYY-DD-MM)

Date to (YYYY-DD-MM)

Total Service

Sign Off Reason

Sign Off Reason Specifically (If select sign off reason as Medical Ground or Other Reasons please specify)

Company / Manning Agent

Flag

Vessel Name

IMO No.

Vessel Type

TEU

GRT

DWT

Engine Make/ Model

BHP

Rank

Date from (YYYY-DD-MM)

Date to (YYYY-DD-MM)

Total Service

Sign Off Reason

Sign Off Reason Specifically (If select sign off reason as Medical Ground or Other Reasons please specify)

Medical History

All previous illnesses other that minor afflictions should be stated below or updated. If not previously disclosed, the Company is entitled to decline payment of medical costs for treatment or for any other insured benefits.

Blood Type

(A) Have you ever signed off a ship due to medical reasons?

Yes

No

If yes, please provide following details (if space is insufficient, attach additional supporting documents)

Name of the Vessel

Date of Occurrence (YYYY-DD-MM)

Place of Occurrence

Supporting Documents (If any)

Brief Description of illness/injury/accident

(B) Have you undergone any surgical operations in the past?

Yes

No

If yes, please provide following details (if space is insufficient, attach additional supporting documents)

Details of Operations

Date (YYYY-DD-MM)

Period of disability

Present Condition

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?

Details of illness/accident

Date (YYYY-DD-MM)

Therapy / Treatment

(D) Please give details of any health or disability problem from which you presently suffer

General

(A) Have you ever been denied a foreign visa?

Yes

No

If yes, state which country and reason (if known)

Country

Reason

(B) Have you been the subject of a court enquiry or involved in a maritime accident?

Yes

No

If yes, please attach details

(C) Curriculum Vitae

Please attach your CV

Declaration to be signed by the applicant

I hereby certify that the information contained in this form is correct and I understand that the Company may terminate my services at any time if any of the above information is found to be false. I understand that a medical examination at my own cost is a condition precedent to selection for employment and I express my willingness to be so examined (if required) and to furnish the company Doctor with full details of my previous medical history.

APPLICATION FORM

Guidelines

Personal Details

Upload Your Photo

1.1 Personal Details

1.2 Contact Details

1.3 Measurements

Personal ID/Documents/Visa

Nominee/Next of Kin and Family Details

3.1 Nominee/Next of Kin Details

3.2 Family Details

First Child

STCW – Compliant Certificates/Courses and Other Qualifications

4.1 Pre-Sea Training (Deck Rating/ Engine Rating/ Marine Skilled Craftsman)

4.2 License

4.3 STCW Certificates

4.4 Other Mandatory / Recommended Certificates / Courses – (as applicable)

Sea Experience

Medical History

(A) Have you ever signed off a ship due to medical reasons?

(B) Have you undergone any surgical operations in the past?

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?

(D) Please give details of any health or disability problem from which you presently suffer

General

Declaration to be signed by the applicant

APPLICATION FORM

Guidelines

Personal Details

Upload Your Photo

1.1 Personal Details

1.2 Contact Details

1.3 Measurements

Personal ID/Documents/Visa

Seaman’s Book (National)

Passport

US Visa C1/D

Yellow Fever

National ID

Nominee/Next of Kin and Family Details

3.1 Nominee/Next of Kin Details

3.2 Family Details

Father

Mother

Spouse

Children

First Child

STCW – Compliant Certificates/Courses and Other Qualifications

4.1 Pre-Sea Training (Deck Rating/ Engine Rating/ Marine Skilled Craftsman)

4.2 License

* License

* Basic / Advance Endorsement

4.3 STCW Certificates

Basic Courses

Advance Courses

4.4 Other Mandatory / Recommended Certificates / Courses – (as applicable)

Sea Experience

Medical History

(A) Have you ever signed off a ship due to medical reasons?

(B) Have you undergone any surgical operations in the past?

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?

(D) Please give details of any health or disability problem from which you presently suffer

General

Declaration to be signed by the applicant