GLORIOUS MARINE (PVT) LTD.

Reg. Address: No.15, Sri Wimalasara Mw.,Gorakana, Panadura, Sri Lanka.

Office Address: 317 1/1, Galle Rd, Gorakana, Panadura, Sri Lanka.
Email : info@gloriousmarine.com Web : www.gloriousmarine.com

APPLICATION FOR RATINGS & OFFICERS

Rank:

1. Personal Details
Name as in Passport:

Nationality: Country of Origin: Date of Birth (DD/MM/YY): Place / City of Birth:

Age: Height: Weight: BMI:

Marital Status: Religion: Willing to accept lower rank? Yes

No
Permanent Address:

City: Country:
Mobile Tel: Home Tel:
SKYPE ID: Email:
Collar: Chest: Waist: Inside leg: Cap:
Sweater Size: Boiler suit size: Shoe size: Overall size:

2. Highest Academic Qualification

From To Institutions/Universities attended Qualification

3. Next of Kin
Name: Relationship: Nationality:

Address: Home Tel: Mobile Tel:

4. Family Details
Relationship First Name Last Name Date of Birth (DD/MM/YY)
Father
Mother
Spouse/Partner
Child M F
Child M F
Child M F

5. Documents & Certificates

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Type of Document Country Number Date of Issue Date of Expiry Issuing Authority
of Issue (DD/MM/YY) (DD/MM/YY) & Place
Passport
Seaman’s Book (National)
COC (Certificate of
Competency)
US Visa

6. STCW-1978 (amended 1995) Compliant Certificate/Courses and Other Qualifications

A. Reg. VI / 1 - Basic Safety Training
Description of Certificate Country Number Date of Issue Date of Expiry Issuing Authority
of Issue (DD/MM/YY) (DD/MM/YY) & Place
Personal Survival
Techniques (PST)
Elementary First Aid
(EFA)

Fire Fighting & Fire

Prevention (FPFF)
Personal Safety and
Social Responsibilities
(PSSR)

B. Reg. VI / 2 - Additional Training

Description of Certificate Country Number Date of Issue Date of Expiry Issuing Authority
of Issue (DD/MM/YY) (DD/MM/YY) & Place
Proficiency in Survival
Craft and Rescue Boat
Fast Rescue Boat
Advance Fire Fighting
(AFF)
Medical First Aid (MFA)
Medical Care
(master/C/D)

C. Reg. VI / 6 - Security Training

Description of Certificate Country of Number Date of Issue Date of Expiry Issuing Authority
Issue (DD/MM/YY) (DD/MM/YY) & Place
Seafarers with
Designated Security
Duties (SDSD)

Ship Security Awareness

(SSA)

D. Other Mandatory/Recommended Certificate

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 Description of Certificate Country Number Date of Issue Date of Expiry Issuing Authority
of Issue (DD/MM/YY) (DD/MM/YY) & Place
ARPA (Automatic Radar
Plotting Aids)
ROP (Radar Observation
& Plotting)
Radar Simulator
Electronic Navigation
Systems (ENS)
BTM (Bridge
Team/Resource Mgmt.)
English Language

Hazmat (US-49CFR)
Ship Handling/Ship
Maneuvering Simulator
Shipboard Security Officer
(SSO)
Watch keeping Certificate
Certificate of proficiency
(COP)

E. GMDSS Certificates (including flag state endorsements)

Description of Certificate Country Number Date of Issue Date of Expiry Issuing Authority
of Issue (DD/MM/YY) (DD/MM/YY) & Place
GMDSS (Main Issuing
Authority)
GMDSS Endorsement

F. Reg. V/1 - Special Requirement for Tankers

Description of Certificate Country Number Date of Issue Date of Expiry Issuing Authority
of Issue (DD/MM/YY) (DD/MM/YY) & Place
Tanker Familiarization
(TFA)

7. Sea Experience
Company Flag & Vessel Type GRT DWT Main BHP Rank Date
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 Name Engine From To

Reference 1 Reference 2
Name of Company:
Name of Person to contact:

Address:

Country:
Telephone/mail:

I hereby declare that the above information provided by me are true and correct to the best of my knowledge.
I understand that company can terminate my services if above information is found to be invalid and falsify.

Signature: Place: Date:

Office Use Only

GM Number : ………………………….……………
Date : ………………………….……………
Registered by : ……………………………………….

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