CREW APPLICATION & MIS DATA CAPTURE

(ORIGINAL TO BE KEPT IN A FILE ON STATION)

ID PHOTO

25
STATION NO
PERSONAL
FIRST NAME: ....................................................................................... KNOWN AS: ...........................................................................................
MIDDLE NAME: .................................................................................... SURNAME: ............................................................................................
ID OR PASSPORT NO: ........................................................................ DATE OF BIRTH: ...................................................................................
GENDER: MALE FEMALE

CONTACT
RESIDENTIAL ADDRESS: .................................................................. POSTAL ADDRESS: ..............................................................................
............................................................................................................... ................................................................................................................
SUBURB: ............................................................................................. SUBURB: ...............................................................................................
CITY: ................................................................. CODE: ...................... CITY: ................................................................ CODE: .........................
CONTACT NO. (H):............................................ (W): .................................................................. FAX: ..................................................................
CELL 1: ................................................................................................ CELL 2: ..................................................................................................
E-MAIL 1: ............................................................................................. E-MAIL 2: ...............................................................................................

GENERAL * Please ensure that the indemnity is signed by 2 witnessess

BUSINESS ADDRESS: ....................................................................... OCCUPATION: ......................................................................................

............................................................................................................... DRIVERS LICENCE NO: ......................................................................
CITY: ............................................................... CODE: ........................ EXPIRY DATE: ................................................ CODE: .........................
MEMBERSHIP CATEGORY: SEA SHORE JUNIOR INDEMNITY DATE*: ..............................................................................

NEXT OF KIN ** Not boyfriend or girlfriend

NAME: .................................................................................................. RELATIONSHIP**: .................................................................................

TEL 1: ................................................................................................... TEL 2: .....................................................................................................
GUARDIAN NAME: .............................................................................. RELATIONSHIP: ....................................................................................
TEL 1: ................................................................................................... TEL 2: .....................................................................................................

MEDICAL
DATE OF MEDICAL: ............................................................................ DOCTOR: ..............................................................................................
ALLERGIES: ..............................................................................................................................................................................................................
CHRONIC CONDITIONS: .........................................................................................................................................................................................
MEDICAL AID NAME: .......................................................................... PLAN: .....................................................................................................
NUMBER: ............................................................................................. PRINCIPAL MEMBER: ..........................................................................

OTHER *** Date of Statcom’s signature is taken as date of joining in respect of service awards

ANY SPECIAL EXPERIENCE OR APTITUDE: ........................................................................................................................................................

DATES OF ANY PREVIOUS NSRI EXPERIENCE: .................................................................................................. NSRI STATION: ..................
DO YOU HAVE A CRIMINAL RECORD?: ................................................................................................................................................................
ARE THERE ANY OTHER CIRCUMSTANCES THAT THE NSRI SHOULD BE AWARE OF?: .............................................................................

APPLICANT’S SIGNATURE DATE STATCOM’S SIGNATURE*** DATE

NSRI | 2015-02