JSM-02-R01

CHECKED BY

PERSONAL RECORD Manager G/Manager

PHOTO ( BIO DATA ) - DECK OFFICER

JSM International Ltd.
Initial entry date Updated Date
Code No Rank Date employed Vessel :
Name :
Note : Myanmar people has no separation of Sur/Given/Middle Name, Above name is as per his passport.
Current Address Tel :
Registered Address
Date of Birth Age Nationality Myanmar Blood Pressure
Place of Birth Height (CM) Clothes size
Marital Status Weight (KG) Shoe size (MM) BMI Result
Family Status Fill in below Yes(Y), No(N) or Nbr.
Father Mother Brother Sister Son Daugther
Next of Kin Name Relation

1. EDUCATIONAL ATTAINMENT
School Majored in Course (From - To) Degree

2. CERTIFICATE OF COMPETENCE (LICENSE) FOR DECK OFFICER.

Country Rank Number Date Issued Expiry Date Issued By
Flag State Panama
Flag State Liberia

National Myanmar DMA, Yangon

Initial issued date of current License DMA, Yangon

3. SEAMAN BOOKS / PASSPORT / SID

Type Number Date Issued Expiry Date Issued By
Passport Myanmar MHA, Yangon
Panama
Seaman Liberia
Book
Myanmar DMA, Yangon
Australian MCV Australia
Seafarers’ Identity Document DMA, Yangon

4. OTHER CERTIFICATES OF COMPETENCE

Kind of Certificate Number Regulation Date Issued Expiry Date Remarks
Other Certificates

5. CERTIFICATES ( STCW 95 )
Kind of Certificate Number Date Issued Expiry Date
GENERAL
Basic Training (STCW 4 items)
AFF "Advanced Fire Fighting"
PSC "Proficiency Survival Craft"
MFA "Medical First Aid"
MCC "Medical Care Cert"
SSO Certificate
DSD Certificate
SSO - Flag State
DSD - Flag State
Radar Observer
BTM
ARPA/ARPA Endorsement
EDH (Deck)
GMDSS/ GOC-National
GMDSS/ GOC-Flag State
FOR TANKER
ECDIS
ACT Endorsement
AOT Endorsement
AGT Endorsement

6. MEDICAL INSPECTION / VACCINATIONS

 JSM-02-R01

Date Issued Expiry Date Remarks

Medical Examination will be done upon owner's approval
Cholera
Yellow Fever
 JSM-02-R01

7. ON-BOARD SERVICE HISTORY FOR LAST 10 YEARS ( approx )

Vessel Name Type GRT Engine Type Tank Coating Manning Crew S/On date Sign off
Period
Flag Rank DWT Output (KW) Cargo Pump Co., Combination S/Off date Reason

8. SHORE CAREERS RELATING TO SHIP / MARITIME / TECHNICAL FIELD ( IF ANY )

Company Type of Job Position Service Duration Remark

9. SPECIAL COMMENTS

Cargo Experience :

Trading Area :

10. INTERVIEWER'S ASSESSMENT : INTERVIEWED BY LOCAL REPRESENTATIVE.

Family Smoking Drinking
A:Married/B:With parants/C:Alone A:None/B:Little/C:1 pack/day A:None/B:One can beer/C:Heavy

Any previous illness English level Eyes

A:None/C:With some remark A:Fluent/B:btwn A and C/C:Poor A:Clear,bright and positive C:Dark and negative

Job ability Motivation to be a seaman Why he wants to change Company.

A:Good/B:Normal/C:Poor A.Positive answer/C:Money purpose

I --------------------------------------------------- here by declear that above decscribed services are true, authentic and no record of Crime or
Black List history in my previous carrieer services . If ther is any dispute regarding Crime or Black List matter, I will follow the
company's instructions and bear the costs for the consequences.

Crew :

Rank -

Name -

Signature -
 JSM-02-R01

10-1). FILLED OUT AND CHECKED BY TEAM LEADER.

10-2). DOUBLE-CHECKED BY TEAM MANAGER.