SEAFARER APPLICATION FORM

DATE APPLIED: PHOTO

POSITION APPLYING FOR: C/M
AVAILABILITY: ANYTIME

PART I - PERSONAL DATA

LAST NAME: FIRST NAME: MIDDLE NAME: CIVIL STATUS:
CATALINO HUTCH MACAYAN SINGLE
PERMANENT ADDRESS: TEL. NO. CELLPHONE NO.
BLK 21 LOT 34 MT. FUJI ST CRESTA VERDE SUBD. NOVALICHES QC. 89376131 9477013379
CONTACT ADDRESS: E-MAIL ADDRESS: RELIGION:
BLK 21 LOT 34 MT. FUJI ST CRESTA VERDE SUBD. NOVALICHES QC. catalinohutch@gmail.com Catholic
DATE OF BIRTH: AGE: PLACE OF BIRTH: HEIGHT: WEIGHT: LANGUAGES SPOKEN: NATIVE FOREIGN
28 Aug. 76 46 QUEZON CITY 5 ' 9 " 180 Lbs. ENGLISH / TAGALOG
BLOOD TYPE: TIN No.: SSS No.: PHILHEALTH No.: PAG-IBIG No.: POEA SRC No.:
B 3342420895 010500294537
WIFE'S FULL MAIDEN NAME: Number of Sons / Daughters: CELLPHONE NO. / E-MAIL ADDRESS:
N/A 2 NIL
1st CHILD GIVEN NAME: AGE: 2nd CHILD GIVEN NAME: AGE: 3rd CHILD GIVEN NAME: AGE: 4th CHILD GIVEN NAME: AGE:
JESS GABRIEL CATALINO 15 ZIAN JED CATALINO 10
FATHER'S FULL NAME: MOTHER'S FULL MAIDEN NAME: NEXT OF KIN: ADDRESS & CONTACT NUMBER:
JESSIE CATALINO CRISELDA MACAYAN CRISELDA MACAYAN SAME AS THE ABOVE
PART II - EDUCATION
LEVEL NAME OF SCHOOL CITY / PROVINCE FROM TO
College PHIL. MAR. INST. Course: BSMT MANILA 93 96
High School
Elementary
PART III - LICENSES
MARINA STCW COC No. CMM200000436119 ( M.M.) DATE ISSUED: 22 NOV. 19 VALID UNTIL: 22-Nov-24
GOC LICENSE No. GOC200006493821 DATE ISSUED: 18 AUG. 21 VALID UNTIL: 18-Aug-26
TESDA NCI/NCIII No. DATE ISSUED: VALID UNTIL:
PART IV - TRAVEL DOCUMENTS
DOCUMENT TYPE NUMBER DATE ISSUED VALID UNTIL DOCUMENT TYPE NUMBER DATE ISSUED VALID UNTIL
PASSPORT P7728327B 30-Sep-21 29-Sep-31 AUSTRALIAN MCV
SEAMAN BOOK C0992536 2-Feb-17 31-Jan-27 YELLOW FEVER VACC.
U.S.A. VISA 22-Jun-21 15-Jun-26 CHOLERA VACC.
PART V - FOREIGN FLAGSHIP DOCUMENTS
DOCUMENT TYPE NUMBER DATE ISSUED VALID UNTIL DOCUMENT TYPE NUMBER DATE ISSUED VALID UNTIL
Panama SIRB Marshall Island End.
Panama GOC Marshall Island Book
Liberia End. Bahamas Endorsement
Liberia Book Bahamas Book
Cyprus End. Malta Endorsement
Cyprus Book Malta Book
PART VI - TRAINING CERTIFICATES
COP CERTIFICATES NUMBER DATE ISSUED TRAINING CENTER CERTIFICATES NUMBER DATE ISSUED
Basic Training BT200046233821 18-Aug-21 Engine Room Simulator
Prof. In Survival Craft & Rescue Boat PSCRB200030144021 18-Aug-21 Auxiliary Machinery System
Advanced Fire Fighting AFF200016392121 18-Aug-21 Control Engineering
Medical Emergency First Aid 18-193680 Hydraulics and Pneumatics
Medical Care 19-55816 Dangerous & Hazardous Materials 139692 13-Oct-05
Ship Security Officer 22-54559 MARPOL (CONSOLIDATED) 14-09-C-08 7-Mar-14
BTOC TESDA (NC1)
ATCT TESDA (NC3)
ATOT Deck / Engine Watchkeeping
Fast Rescue Boat (FRB) PFRB200002060921 18-Aug-21 Welding Course
SDSD 27-147637 Lathe Machine Course
TRAINING CENTER CERTIFICATES NUMBER DATE ISSUED Practical Assessment
Safety Officer Course 0614511709 20-Jun-14 Culinary / Catering Course
Risk Assessment Messman Course
Incident Investigation CROWD AND CRISIS MGT.

ECDIS GENERIC Shore-based Fire Fighting

ECDIS SPECIFIC Crude Oil Washing
Bridge Resourse/Team Mgmnt. Inert Gas System
FRAMO Course
SSBT 0409-05021 3-Apr-09
Free-Fall Lifeboat Familiarization
Ship Handling Course 2011-4933 13-May-11
INMARSAT/SATCOM Environmental Management

GMDSS Human Relationship

ROC/ROP Bilge Water Waste Management

ARPA Tank Atmospher & Gas Measurement

RSC Automatic identification System 05-24-01 28-Oct-05

SRROC BTLGT
PART VII - DETAILS OF SEA-GOING EXPERIENCE (Starting with the LATEST in chronoligical order)
MAIN ENGINE PERIOD(dd-mm-yr)
Year Built
Vessel Name Vessel Type Flag GRT Rank Maker Type or Model BHP Rank Sign-on Sign-off Total service Trade Route Reason for sign-off Manning Agency
Vessel Name Vessel Type Flag GRT Column1 Year Built Maker Type BHP Rank Sign-on Sign-off Column2 Trade Route Reason for sign-off Manning Agency

M/V DINO BULK PANAMA 21,192 C/M 20.09.20 23.02.21 05.02 W/W ASYMPTOMATIC (COVID) TDG

M/V ALONI BULK PANAMA 21,192 2/O 20.11.18 17.09.19 09.27 W/W EOC TDG

M/V GRIKO BULK PANAMA 17,944 2/O 02.06.17 29.03.18 09.27 W/W EOC TDG

M/V KAMBOS BULK PANAMA 21,192 2/O 13.02.16 25.11.16 09.08 W/W EOC TDG

M/V GOLDEN ROSE BULK MAJURO 44,485 2/O 22.07.14 23.04.15 09.01 W/W EOC TSM

M/V OSHIMA ISLAND BULK SINGAPORE 42,960 2/O 01.06.13 04.01.14 06.03 W/W CHANGE CREW DOLPHIN
M/V OCEAN
PROMISE BULK SINGAPORE 29,841 3/O 19.03.12 14.11.12 08.11 CHINA/PHIL/INDONISIA EOC DOLPHIN

M/V MANHATTAN CONTAINER LIBERIA 54,592 3/O 05.06.11 12.12.11 06.06 W/W EOC PTC
M/V MAERSK
DAMIETTA CONTAINER LIBERIA 54,675 3/O 15.08.10 20.02.11 06.05 W/W EOC PTC

M/V MANHATTAN CONTAINER LIBERIA 54,592 3/O 12.11.09 18.05.10 06.06 W/W EOC PTC

M/V ARYA PAYAM BULK CYPRUS 32,474 3/O 17.08.08 13.02.09 05.26 W/W EOC INC

M.V. APL SEATTLE CONTAINER LIBERIA 35,255 3/O 25.05.07 29.03.08 10.04 W/W EOC INC

M.V. SEA BREEZE CONTAINER MARSHALL ISL 7,701 3/O 27.01.06 01.12.06 10.04 W/W EOC INC
M.V. NORASIA
TEGESOS CONTAINER CYPRUS 31,207 J/O 30.11.04 24.09.05 09.26 W/W EOC INC
PART VIII - CONTACT DETAILS OF AT LEAST 3 FOREIGN PRINCIPALS
COMPANY NAME OFFICE ADDRESS CONTACT NUMBERS E-MAIL ADDRESSES / FAX NUMBER

PART IX - DETAILS OF WORK EXPERIENCE ASHORE, IF ANY

COMPANY NAME & ADDRESS POSITION FROM TO JOB DESCRIPTION REASON FOR LEAVIING

PART X - MEDICAL BACKGROUND

YES NO
Please type "X" (IF YES, PLEASE DESCRIBE)
Any Previous Surgery? X GALLBLADDER
Any Previous Serious Illness / Injury / temporary disability? X
Any Physical Handicap? X
Any Drug Related Problem? X
Any Alcohol Related Problem? X
Any involvement in an accident resulting to loss of life or NOTE: In case and in the event that I withdraw my documents
X after approval by the principal, I hereby agree to pay and
personal injury or damage to ship, cargo, pollution, etc.? reimburse all the expenses for processing fees and cost (POEA
PART XI - CHARACTER REFERENCES Contract, PEME, Visa, Flags, Trainings and other Certificates)
NAME / POSITION COMPANY NAME / ADDRESS CONTACT NUMBERS / E-MAIL Unless the withdrawal is due to the fault of the principal or the
company. Document release shall be affected within five (5)
working days after the request is made, provided further that
all fees and cost have been paid.

I HEREBY, certify that I have not been involved, charged or convicted in any administrative civil and/or criminal or tribunal in any jurisdiction either local or international in connection with my employment as a seafarer onboard ocean going vessel.
I futher certify that I have not been involved, charged or convicted in any administrative, civil or criminal court or tribunal for cases associated with magic pipes and other similar activities in any U.S. Jurisdiction neither was I been deported or placed under blacklist
by the U.S. Coast Guard and or the U.S. Environmental Protection Agency as consequence thereof.
I HEREBY CERTIFY that the information above is true and correct. Any misrepresentation or misinformation on my part shall be grounds for the revocation of my application and if already employed, shall be ground for termination without any responsibility / liability on the part of Global Gat
Crewing Services, Inc. whatsoever.
Applicants Signature ____________________________________ Date: _____________________