SEAFARER EMPLOYMENT APPLICATION FORM

Date Today (DD/MM/YEAR):

PHOTO
Position Applied for : 2X2
Availability :

Last Position Held :

I.PERSONAL DATA :
First Name : Middle Name : Surname :

Contact Address: Tel. No.: Cellphone No. : Height:

Date of Birth: Email Address / Other Contact No.: Weight:

II. EDUCATION
Level Name of School/College From To City / Province Degree Earned
College
III. DOCUMENTS
Documents Number Date Issued Valid Until Documents Number Date Issued Valid Until
Passport: PH Schengen Visa:
Seaman's Book: PH Panama SIRB:
US Visa C1/D Panama GOC:
POEA SRC No: Yellow Fever Vacc.
IV. LICENSE / CERTIFICATE OF ENDORSEMENT
Documents Number Date Issued Expiry Date Documents Number Date Issued Expiry Date
PH - COC Isle of Man-IOM
PH- COE Singapore - COC

UNCONTROLLED COPY
PH - GOC GMDSS Singapore -GMDSS
V. TRANING CERTIFICATES - COP
Documents Cert. Number Date Issued Valid Until Documents Cert. Number Date Issued Valid Until
Basic Training - BT PSCRB
BTLGT MEFA
ATLGT MECA
AFF SDSD SSAT
VI. CERTIFICATES HELD AND COURSES ATTENDED
Documents Cert. Number Date Issued Expiry Date Documents Cert. Number Date Issued Expiry Date
Basic Training - BT SSBT WITH BRM
BTLGT Bridge Team Mngt.
ATLGT ERS WITH ERM
AFF ECDIS 2012 Edition
PSCRB GMDSS
MEFA Ship Handling Course
MECA SSO - C/O
SDSD SSAT Food Hygiene (CCK)

Marpol Consolidated Ship Security Officer-ALL

Officer
Radar Observer Anti - Piracy
PDOS Medical Certificate
Other National Other National
Certificates Certificates

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VII - PREVIOUS SEA EXPERIENCE ( MOST RECENT EXPERIENCE ON THE TOP LINE )

Ship Manager or Manning Office or

Name of Vessel Rank Type of Vessel Gross Tonnage CM3 (Gas) Engine
Power Date Signed On Date Signed Off Total No. of Technical Local Manning
/DWT (Bulk) Type/Make MM-DD-YY MM-DD-YY Days onboard Manager Office

UNCONTROLLED COPY

*Use only following abbrevations for Vessel types:

GAS 1: Pressurized VLGC - Very Large Gas Carrie CHM - Tanker (Chemical) CON - Container SRV - Survey Vessels
GAS 2: LPG - Semi-Refrigerated LNG - LNG Gas Carrier TOC - Tanker (Oil/Chem combo) PAS - Passenger (Ferry) OSV - Off Shore Supply Vessels
GAS 3: LPG - Fully – Ref. TNC - Tanker (Crude Oil) TNV - VLCC / ULCC R/O CRU - Passenger (Cruise) GC - General Cargo
GAS 4: LPG - Ethylene TNP - Tanker (Products/Oil) B/C - Bulk Carrier OBO - Ore/Bulk/Oil Carrier
By signing this form, I hereby declare that;
- the above information are true and good faith, any misleading information can be taken against me in the court of law of the Republic of the Philippines,
- I have read and understood UCPI Privacy Notice for Applicant.

Signature over printed name: _____________________________________________

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