OSP/CREW 11.80.448.1615.

8314 Revision: 03 Issued Date : 14/12/2020

APPLICATION FORM - MARINE PERSONNEL

POSITION APPLIED FOR :

Are you willing to accept a lower position ?

Date available if selected ?

PHOTO

Surname :

First Name : Mid Name :

Marital Status : Nationality :

Date of Birth : Age: Place of Birth:

Height (cms) : Weight (kgs) : Shoe Size : Blood Group :

UK / USA / Europe
INDOS Number : Boiler Suit Size :

Address (1) : Telephone :

(Present) Mobile :
E-mail :
Skype ID :

Address (2) : Telephone :

(Permanent) Mobile :
E-mail :
Skype ID :

Nearest Airport:
(International) (Domestic)

FAMILY DETAILS

Next of Kin : Relation :

Address : Telephone :
Mobile :
E-mail :

Date of Birth
Children : Name Sex
(dd/mmm/yy)

EDUCATION / TRAINING (Academic / Professional)

Period (dd/mm/yy)
School / College / Institution Attended Certificate / Diploma obtained
From To

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MEDICAL HISTORY

Have you ever signed off any ship due to medical reasons ?
Have you undergone any surgery in the past ?
Have you consulted a doctor during the last 12 months for any illness or accident ?
Have you ever been tested positive for any drug and alcohol test ?
(Please mention Yes, No or N/A if the form is being filled manually)
If the answer is YES to any of the above, please give full details below and attach a separate page if necessary

TRAVEL DOCUMENTS AND COMPETENCY CERTIFICATES (Date in dd/mm/yy)

Place of
Document Capacity / Grade Cert. No. Issued Date Expiry Date Remarks
Issue
Passport -
U.S visa (C1/D) -
U.S visa (B1/B2) -
Medical Certificate -
INDOS Number -
Yellow Fever -
National
Malta
Seaman's book

Liberia
NIS
Bahamas
Bermuda
Panama
Others
National
Certificate of Competency or

Malta
Hong Kong
Singapore
Equivalency

Liberia
NIS
Bahamas
Bermuda
Panama
Isle Of Man
Others
Watchkeeping Deck / Engine
Ratings

COP Able Seafarer Deck / Engine

Others
Oil
Singapore National

Chem
Gas
Dangerous Cargo Endorsement

Oil
Chem
Gas
Hong Kong
Malta
Liberia
NIS
Bahamas
Bermuda
Panama
Others Please specify flag :
National
Malta
Hong Kong
Singapore
GMDSS

Liberia
NIS
Bahamas
Bermuda
Panama
Others Please specify flag :

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PROFESSIONAL COURSES (Date in dd/mm/yy)

Type Certificate Number Date Issued Institute / Remarks

Basic Safety Training

- Basic Fire Fighting
- Personal Survival Techniques
- Personal Safety & Social Responsibility
- Elementary First Aid
STSDSD / Ship Security Officer
Advanced Fire Fighting
Proficiency in Survival Craft & Rescue Boat
Ship Captain's Medicare
Medical First Aid
Radar, ARPA & Navigation Simulator (NARAS / RANSCO)
Radar Observervation and Plotting (ROC)
Automatic Radar Plotting Aid (ARPA)
Basic Tanker Familiarization - Oil
Basic Tanker Familiarization - Gas
Basic Tanker Familiarization - Chemical
Specialised Tanker Safety Course (Oil) - TASCO
Specialised Tanker Safety Course (Gas) - GASCO
Specialised Tanker Safety Course (Chemical) - CHEMCO
Electronic Chart Display & Information Systems (ECDIS Generic)
ECDIS Type Specific : JRC
MARIS
Furuno ( FMD MODEL 3100, 3200 & 3300)
Tokyo-Keiki
ChartWorld eGlobe G2
Others -
Watchkeeping for Engine Room Watches (E/R Ratings)
Watchkeeping for Navigational Watches (Deck Ratings)
AMOS (or any other electronic Planned Maintenance System) *
Assessor
Bridge Team Management
Bridge/Engine Resource Management
Catering or Cooking Course
Collision Avoidance Course
Computer Knowledge
Corrosion Protection & Painting Course
Engine Room Simulator *
FRAMO Pump
High Voltage Training
Hydraulics and Pneumatics
Incident Investigation
Internal Auditor's Course
Liquid Cargo/Ballast Handling Simulator *
MAN B&W Electronic 'ME' Engines
Marine Electrical
Mooring Course
NABCO M/E Manoeuvring & Control *
Port State Control
Radar Maintenance Course
Ship Manoeuvring Simulator & Bridge Teamwork
Ship Safety Officer
Welding Course
Others than above :
1) Please mention the level/category of course in remarks column if marked with an asterisk *
2) Details of any additional courses attended to be filled-up in the blank spaces

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SEAGOING EXPERIENCE (If space not sufficient below, please use separate sheet)

Period of Service
M/E Type BHP (for (dd-mm-yy)
Rank Name Of Vessel Your Employer Vessel Type* GT Days
(for Engr)* Engrs)
From To

* Please complete the 'vessel type' or 'engine type' categories as per nomenclature below, in case application form is being completed by hand

CONSOLIDATED SEAGOING EXPERIENCE

Deck Officer Rank Served Years Months Engineer Officer Rank Served Years Months
Product Carrier B&W (SM-C)
Crude Carrier B&W (ME-C)
VLCC / ULCC B&W (ME-B)
Chemical Carrier SULZER (RTA)
Chem/Oil Carrier DFDE
FRAMO MAN MEGI
COPT FRAMO
LPG / LNG COPT
Bulk Carrier Mitsubishi
OBO Gas Turbine
General Cargo / Cont. Steam Turbine
Others UMS

REFERENCES (Must mention details of person to contact from applicant's last employers. Reference check shall not be taken without the consent of applicant)

Name Company Contact details

Have you been involved in either or both of the following, during service with any of your previous employers?
(a) a maritime accident involving loss of life and/or a considerable loss of property
(b) an incident involving oil pollution damage to environment

If the answer to above is YES, please give details and attach a separate page if necessary

I certify that the above information is true and correct. I fully understand and agree that any false declaration herein above shall result in instant dismissal without any
responsibility or liability whatsoever on the part of the company.

Date : Applicant

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