mma - application form (latest)
TRANSCRIPT
# Form have to be completely filled with information and signed * Dates to be in entered in DD/MM/YY format
A.
B.
C.
D.
E.
F.
No DP System
1 NIL
2 NIL
3 NIL
4 NIL
5 NIL
6 NIL
7 NIL
8 NIL
9 NIL
10 NIL
11 NIL
12 DP-1
13 NIL
14 DP-1
14871AC879E81D2CTest Licence Code
Advance Fire Fighting (A-VI/3)
INDONESIA
04/12/12
YES
02/07/20
YES
02/07/156200073545060315
02/07/15
01/10/17
31/12/16
Revalidated (Yes or No)
Certificate Class
YUSRI TRIMAINI
YES
JAKARTA
N/A
PTSC VIETNAM,
CARIGALI PETRONAS
/ DULANG OIL FIELD
JASMIN OIL FIELD
MUBADALA,
SATTAHIP GULF OF
AHTS
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
05/08/2011
19/02/2012MASTER
AHTS
2005..
Singapore
Singapore
Anchor Handling,Rig
Move,Towing, Static
Tow.Lifting Tanker,
Jaya Base
Anchor Handling,Rig
Move,Towing, Static
Tow.Lifting Tanker, Anchor Handling,Rig
Move,Towing, Static
Tow.Lifting Tanker,
Singapore
Anchor Handling, Rig
Move,Towing , Static Tow,
Lifting Tanker (PTSC
Delivery new ship from
Guangzou china
Delivery new ship from
yue xien china China, Singapore
JASMIN OIL FIELD
MUBADALA,
SATTAHIP GULF OF JASMIN OIL FIELD
MUBADALA,
SATTAHIP GULF OF
THAILAND
PERTAMINA
TONGKANG, JAVA
SEA , MADURA OIL
JAYA BASE SINGAPORE
JASMIN OIL FIELD
MUBADALA,
SATTAHIP GULF OF JASMIN OIL FIELD
MUBADALA,
SATTAHIP GULF OF
16/02/2007
Singapore
Singapore
Singapore
20/08/2005Chest boat, running
cargo, supply boat.
Delivery new ship from
Guangzou china
19/06/2006
25/09/2006
INDIA, DEEP DRILLER,
MYANMAR YANGON.
China, Singapore
China, Singapore
Anchor Handling,Rig
Move,Towing, Static
Tow.Lifting Tanker,
Maintenance Platform,
Date of Availability* ANYTIME
INDONESIA
F (14), F (11), M (8)
28/09/1528/10/14
Wartsila MASTERBunker Barge Malaysia,
Singapore.
Bunker Barge, Malaysia,
Singapore.M'SIA
NO
YES
2005..
Tanjung Balai Karimun Drug & Alcohol Date*
04/09/20
2010
Working Shoe Size
Year (e.g 1990 - 1995)
XXL
Passport Expiry Date*
Seaman Book Expiry*
Medical History (if any)
23/05/18
11
Home Telephone No. + 62 81372337244
Hindun Deceased (Yes or No) Father's Name & Age H.M.SYAICHU Deceased (Yes or No) YES
Name of Spouse
N/A
N/A
02/02/2011
14/09/2011
Rank in DPDP1/DP2/D
P3
6200073545080315 02/07/15
Singapore
Singapore
Singapore
2005..
2005..
Anchor Handling,Rig
Move,Towing, Static
Tow.Lifting Tanker,
10/01/2003
02/05/2006
06/10/2004
Ch.Ofc
24/09/2006
MV.DJM FORTUNE 3
MV.JAYA AMANDAM
MASTER
Caterpillar
Caterpillar
Caterpillar
Wartsila
617
1204
1204
1459
214
ISM Code
30/11/2004
19/05/16
19/05/16
23/09/17
Signed
Off*
29/09/17
23/09/14
Helicopter Landing Officer (HLO)
HUET
939257072008144000
RankSigned
On*
M'SIA
Description of Certificate
Unlimited Full DP Certificate
DP Basic (Induction)
26/08/2002
BASIC TRAINING FOR OIL AND CHEMICAL TANKER
Ship's Crane Operator
YES
30/06/20
MV.JAYA PUFFIN 5
MV.DJM FORTUNE 3
MV.MARINA
MV.JAVA CHALLENGER
MVJAYA SUPPLIER 3
MV. SEA INTREPID
MV. JAYA PUFFIN 3
MV.DJM FORTUNE 3
Supply
Utility
AHTS
AHTS
1204
AHTS
AHTS
AHTS
Detroit
61100789DI
2300
DP OPERATOR SKILL RETENTION&ENHANCEMENT TRAINING 08/03/14
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
1459
AHTS
AHT
AHTS
AHTS
Radar & ARPA
APPLICATION FOR THE POSITION OF: MASTER
CURRICULUM VITAE (CV)
Contact No. 2
Nationality & Race
SURABAYA
24/04/70
Contact No. 1MUHAMMAD IRHASJ HARIS
PERSONAL DATA
N/A
INDONESIAN & MALAY
Name (Exactly As in Passport)
Place of Birth
Date of Birth*
+ 62 81372821236
MV.DJM FORTUNE 3
MVJAYA MARINER 2
MV.JAYA AMARA
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore 1
Caterpillar
Wartsila
Wartsila
18/04/2010
Anchor Handling,Rig
Move,Towing, Static
Tow.Lifting Tanker,
12/04/200912/04/2007
14/04/2009
11/10/2010
Singapore
Singapore
Singapore
Caterpillar
Caterpillar
1470
1470
1204
1491
Ch.Ofc
21/08/2005
Ch.Ofc
Ch.Ofc 2005..
11/11/2005
Caterpillar
Caterpillar
Religion
SINGAPORE
MALAYSIA
Medical Certificate Expiry*
married
+ 62 81261625756
Gender & Age
26/12/17
3
Same as Above address
No. of Children
N/A
Issued Date*23/09/10
04/08/15
COE-D0118896
YUSRI TRIMAINI
MOESLEM
23/06/1723/06/2015
16/09/15
Expiry Date*
N/A
31/12/16
Wartsila
02/07/20
Certificate No.
855
02/07/20
02/07/20
YES
Flag
LOCAL OWNER, PORT
KLANG, MALAYSIA
Country of Issuance
INDONESIA
INDONESIA
Relationship
02/07/20
Type and number of
offshore operations
carried out
13/01/2003MASTER
DP ADVANCED / S694/12
MASTER UNLIMITED
CLASS 1 (ONE) 6200073545N10210
6200073545N10210
Tanker
Type of VesselEngine
Type
02/07/20 YES
Expiry Date*
YES
YES
Issued Date*
19/11/15
Date Due for Revalidation*
Limitations Applying (if any)
N/A
WIFE
Singapore COE SINGAPORE
National GMDSS / GOC
National GMDSS / GOC Endorsement
Jl. Bangka Komplek Timah D. 79, RT 002, RW 005, Teluk Uma, Tanjung Balai Karimun, Indonesia
Country of Issuance
INDONESIA
INDONESIA
Contact No.
Major
BP3IP, JAKARTA
MT.AROWANA 2 BHL, Malaysia
GRTCompany & Country
6200073545210312
Ship Security Officer (A-VI/5 & B/VI-5)
Vessel Name
CERTIFICATE OF COMPLETION
CLASS 1 (ONE)
A1,A2,A3 and A4
N/A
Description of Certificate
Basic Safety Training (A-VI/1-1 to 1-4)
SEA SERVICES RECORD AS IN SEAMAN BOOK. INDICATE
MAXIMUM
Azimuth Thruster 360 Deg.
COURSE ATTENDED & CERTIFICATES OBTAINED
Certificate No
6200073545030315
Basic Firefighting (A-VI/1-2) N/A
Medical Care On Board (A-VI/4-2)
6200073545040315
26/12/12
EDUCATIONAL BACKGROUND
Highest Qualification Attained
National Certificate of Competency
National Certificate of Competency Endorsement
02/07/15 02/07/20
Personal Survival Techniques (A-VI/1-1) 6200073545010315 02/07/15 02/07/20
Elementary First Aid (A-VI/1-3)
Issued Date*
N/A
6200073545010315
N/A
Marlins Test Score 83% Test Location
MARINE TECHNOLOGIES SINGAPORE
Charter & Areas
of Operations
THE DP CENTRE, SINGAPORE
02/07/15
YES
YES INDONESIA
NO
INDONESIA
Personal Safety & Social Responsibility (A-VI/1-4) N/A
Country of Issuance
LONDON,UK
INDONESIA
04/03/2004/03/15 YES INDONESIA
INDONESIA
INDONESIA
02/07/15 02/07/10 YES INDONESIA
20/08/14 19/08/18
27/03/99
10/01/13 10/01/18
02/07/15
N/A
LOCAL OWNER, PORT
KLANG, MALAYSIA
13/12/12
THE DP CENTRE, SINGAPORE
Expiry Date*
19/11/20
MSA, Malaysia
MUST BE TRUE and HONEST in SEA SERVICES and Previous RANK - SEA TIME STATED BELOW MUST BE THE SAME WITH SEAMAN BOOK & DP LOGBOOK
19/05/11DP BASIC / S245/11
MASTER
MASTER
MASTER
Ch.Ofc
Ch.Ofc
Ch.Ofc
Current Salary in USD
International Passport No.
Seaman Book No.
Working Coverall Size
Body Weight in KG
Medical Certificate Issue Date*
Email Address
Expected Salary in USD
B 1240537
Y 041579
85 Height in CM 178
N/A
Main Airport Name
Marital Status
DP CERTIFICATION
2. 055 /ISM/BPLP SMG./III/99
Certificate No
26984
Limited DP Certificate
DP Advance (Simulator)
Next of Kin Name (Emergency)
Security Awareness Training (A-VI/6-1)
6200073545280313
Next of Kin Address
Description of Certificate
Highest School Attended
Mother's Name & Age
Home Address
CERTIFICATE OF COMPETENCY
COE-R0063809Singapore GOC
Malaysia COR
6200073545240315
Security Training for Seafarers with Designated Security Duties (A-VI/6)
Medical First Aid On Board (A-VI/4-1) 6200073545070315
13/01/2011
1
6200073545230315 02/07/15 02/07/20
N/A
Bridge Resource Management (A-II/2)
ECDIS (A-II/1 & A-II/2)
6200073545390315
30/06/15
02/07/15
INDONESIA
Survival Craft & Rescue Boat (A-VI/2 para 1-4)
Fast Rescue Craft (A-VI/2 para 5-8)
N/A
N/A
NO
6200073545020315
BOSIET / FOET
INDONESIA
Radar Observer INDONESIA
INDONESIA
OIL TANKER SPECIALIZED TRAINING PROGRAMME 6200073545100315 02/07/15 02/07/20 YES INDONESIA
NO
INDONESIARIGGING,SLINGING AND LIFTING TRAINING
IMDG CODE
H2S
6200073545290315
INDONESIA
NO
H2S.00735/OTM/2014
RSLT.00733/OTM/2014
29/09/14
INDONESIA
FWM 2/23/20167:32 PM
15 DP-1
16 DP-1
17 DP-1
18 DP-1
19 AHTS DP-1
20 DP-2
21 DP-2
22 NIL
23 DP-1
G. H.
No
1
2
3
4
5
Towing, Rig Move, Anchor
Handling, Maintenace
platform, Running Cargo,
Drilling Support, Seismic
Seismic Support
MURPHY OIL
MALAYSIA WEST
PATRICIA OILFIELD
BINTULU SARAWAK /
PETRONAS CARI GALI,
CGG Baram Field,
Ch.Off JDPO
MASTER
Ch.Off JDPO 06/01/2015
25/02/2015
19/01/2016
05/07/2015
Labuan
SingaporeDJM FORTUNE 3
Jaya Offshore Pte Ltd Singapore
MERMAID MARINE AUSTRALIA PTE.LTD
AHTS
AHTS
2 3607
1204
Towing, Rig Move, Anchor
Handling, Maintenace
platform, Running Cargo,
Drilling Support, Seismic
MURPHY OIL
MALAYSIA WEST
PATRICIA OILFIELD
BINTULU SARAWAK /
JAYA AMANDAM Jaya Offshore Pte Ltd Singapore 1 1459
SEA HAWK 1 Jaya Offshore Pte Ltd Singapore AHTS 2 2952 Wartsila Ch.Off JDPO Ch.Off JDPO 21/10/2014
20/03/2014
MUHAMMAD IRHASJ HARIS
10/12/2015
28/01/2013
01/10/2013
18/09/2015
20/06/2014 Singapore
Anchor Handling,Rig
Move,Towing ,
Maintenance Platform,
Running Cargo, Drilling
BSP (BRUNEI SHELL
PETROLEUM),
BRUNEI OILFIELDS
CHAMPION,AMPA,
Drilling Support,
Maintenance Platform,
Running Cargo
Singapore
Singapore
Anchor Handling,Rig
Move,Towing ,
Maintenance Platform, Anchor Handling,Rig
Move,Towing ,
Maintenance Platform, Anchor Handling,Rig
Move,Towing ,
Maintenance Platform,
Running Cargo, Drilling Anchor Handling,Rig
Move,Towing ,
Maintenance Platform,
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
Jaya Offshore Pte Ltd Singapore
AHTS
AHTS
AHTS
Singapore
BSP (BRUNEI SHELL
PETROLEUM),
BRUNEI OILFIELDS Jaya Offshore Pte Ltd Singapore
AHTS
BSP (BRUNEI SHELL
PETROLEUM),
BRUNEI OILFIELDS
CHAMPION,AMPA, BSP (BRUNEI SHELL
PETROLEUM),
BRUNEI OILFIELDS MASTER
MASTER
BSP (BRUNEI SHELL
PETROLEUM),
BRUNEI OILFIELDS
23/04/2012 Singapore
Singapore
MASTER
MASTER
MASTER
1458
1458
1459
Wartsila
Wartsila
Wartsila
1458
02/10/2012
06/01/2015 Labuan
MV.JAYA AMETHYST
MV.JAYA AMETHYST
MV.JAYA AMETHYST
JAYA AMANDAM
PETRONAS. Yetagun
Field, Myanmar.
30/08/2012
10/12/2012
10/06/2013
11/01/2014
1458
CaterpillarMERMAID MARINE AUSTRALIA PTE.LTD MASTER
Wartsila
Wartsila
Date*
DECLARATION
I hereby declare that the information furnished above is true to the best of my knowledge.
Contact NumberName of Company Name of Contact Person Email
AHTS
1
1
1
1
1
Caterpillar
Wartsila
JAYA ALMIGHTY
JAYA MAJESTIC
REFERENCES
Signature
FWM 2/23/20167:32 PM
Rec
ent P
hoto in
JPEG
(Com
pulsory
)
Rec
ent P
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JPEG
(Com
pulsory
)
Rec
ent P
hoto in
JPEG
(Com
pulsory
)
14871AC879E81D2C
INDONESIA
4750
3500
4750
1200
5150
4800
5150
ANYTIME
INDONESIA
F (14), F (11), M (8)
04/09/20
2010
23/05/18
11
+ 62 81372337244
YES
N/A
Finished
Contract
Finished
Contract
4750
Rec
ent P
hoto in
JPEG
(Com
pulsory
)
N/A
INDONESIAN & MALAY
+ 62 81372821236
4000
4800
Finished
Contract
4000
SINGAPORE
MALAYSIA
+ 62 81261625756
MOESLEM
23/06/17
3200Finished
Contract
Country of Issuance
INDONESIA
INDONESIA
Finished
Contract
Finished
Contract
Transfer Ship
Transfer Ship
Transfer Ship
N/A
WIFE
SINGAPORE
Country of Issuance
INDONESIA
INDONESIA
MARINE TECHNOLOGIES SINGAPORE
BHP/K-WATT
THE DP CENTRE, SINGAPORE
Reason For
Leaving
INDONESIA
INDONESIA
Country of Issuance
LONDON,UK
Finished
Contract
INDONESIA
INDONESIA
INDONESIA
INDONESIA
INDONESIA
THE DP CENTRE, SINGAPORE
MUST BE TRUE and HONEST in SEA SERVICES and Previous RANK - SEA TIME STATED BELOW MUST BE THE SAME WITH SEAMAN BOOK & DP LOGBOOK
3400
Transfer Ship
Finished
Contract
4750
Transfer Ship
Transfer Ship
INDONESIA
INDONESIA
INDONESIA
INDONESIA
INDONESIA
INDONESIA
INDONESIA
INDONESIA
FWM 2/23/20167:32 PM
12070
4750
Finished
Contract
Finished
Contract
12070 Transfer Ship
4800
5150
Finished
Contract
4800
4800
4800
4800
Finished
Contract
Finished
Contract
Finished
Contract
Finished
Contract
Finished
Contract
Date*
DECLARATION
I hereby declare that the information furnished above is true to the best of my knowledge.
FWM 2/23/20167:32 PM
# Form have to be completely filled with information and signed * Dates to be in entered in DD/MM/YY format
A.
B.
C.
D.
E.
F.
No DP System
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
G.
1 2 3 4 5
6 7 8 9 10
H. I.
No
1
2
3
4
5
Place of Birth Contact No. 2
Date of Birth* Nationality & Race
APPLICATION FOR THE POSITION OF:
Rec
ent P
hoto in
JPEG
(Com
pulsory
)
CURRICULUM VITAE (CV)
PERSONAL DATA
Name (Exactly As in Passport) Contact No. 1
International Passport No. Passport Expiry Date*
Seaman Book No. Seaman Book Expiry*
Current Salary in USD Expected Salary in USD Date of Availability*
Working Coverall Size Working Shoe Size
Body Weight in KG Height in CM Religion
Medical Certificate Issue Date* Medical Certificate Expiry*
Email Address Skype ID Medical History (if any)
Main Airport Name Drug & Alcohol Date*
Marital Status Name of Spouse No. of Children Gender & Age
Mother's Name & Age Deceased (Yes or No) Father's Name & Age Deceased (Yes or No)
Next of Kin Address Contact No.
EDUCATIONAL BACKGROUND
Home Address Home Telephone No.
Next of Kin Name (Emergency) Relationship
Marlins Test Score Test Location Test Licence Code
Highest School Attended Year (e.g 1990 - 1995)
Highest Qualification Attained Major
CERTIFICATE OF COMPETENCY
Description of Certificate Certificate Class Certificate No. Issued Date* Expiry Date* Limitations Applying (if any) Country of Issuance
National Certificate of Competency Endorsement
National Certificate of Competency
National GMDSS / GOC Endorsement
National GMDSS / GOC
Singapore GOC
Singapore COE
Basic Safety Training (A-VI/1-1 to 1-4)
COURSE ATTENDED &
CERTIFICATES OBTAINED
Description of Certificate Certificate No Issued Date* Expiry Date* Revalidated (Yes or No) Country of Issuance
Malaysia COR
Basic Firefighting (A-VI/1-2)
Personal Survival Techniques (A-VI/1-1)
Personal Safety & Social Responsibility (A-VI/1-4)
Elementary First Aid (A-VI/1-3)
Fast Rescue Craft (A-VI/2 para 5-8)
Survival Craft & Rescue Boat (A-VI/2 para 1-4)
Medical First Aid On Board (A-VI/4-1)
Advance Fire Fighting (A-VI/3)
Ship Security Officer (A-VI/5 & B/VI-5)
Medical Care On Board (A-VI/4-2)
Security Awareness Training (A-VI/6-1)
Security Training for Seafarers with Designated Security Duties (A-VI/6)
Maintenance of Electrical & Electronics Equipment
Engine Room Resource Management
BOSIET / FOET
High Voltage Certificate
H2S
HUET
Any other certs (please indicate)
DP CERTIFICATION
Description of Certificate Certificate No Issued Date* Expiry Date* Date Due for Revalidation* Country of Issuance
Azimuth Thruster 360 Deg.
DP System Maintenance
SEA SERVICES RECORD AS IN
SEAMAN BOOK. INDICATE
MAXIMUM
MUST BE TRUE and HONEST in SEA SERVICES and Previous RANK - SEA TIME STATED BELOW MUST BE THE SAME WITH SEAMAN BOOK & DP LOGBOOK
Vessel Name Company & Country Type of VesselDP1/DP2/D
P3GRT
Engine
TypeRank BHP/K-WATT
Reason For
Leaving
Signed
On*
Signed
Off*Flag
Type and number of
offshore operations
carried out
Charter & Areas
of Operations
INDICATE SOME ENGINE MODEL
NUMBER.EXAMPLE OF ENGINE MODEL AS BELOW
Remarks
REFERENCES DECLARATION
Name of Company Name of Contact Person Email Contact Number
Signature Date*
I hereby declare that the information furnished above is true to the best of my knowledge.
FWM 2/23/20167:32 PM
# Form have to be completely filled with information and signed * Dates to be in entered in DD/MM/YY format
A.
B.
C.
D.
E.
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
F.
1 2 3 4 5
6 7 8 9 10
G. H.
No
1
2
3
4
5
Place of Birth Contact No. 2
Date of Birth* Nationality & Race
APPLICATION FOR THE POSITION OF:
Rec
ent P
hoto in
JPEG
(Com
pulsory
)
CURRICULUM VITAE (CV)
PERSONAL DATA
Name (Exactly As in Passport) Contact No. 1
International Passport No. Passport Expiry Date*
Seaman Book No. Seaman Book Expiry*
Current Salary in USD Expected Salary in USD Date of Availability*
Working Coverall Size Working Shoe Size
Body Weight in KG Height in CM Religion
Medical Certificate Issue Date* Medical Certificate Expiry*
Email Address Skype ID Medical History (if any)
Main Airport Name Drug & Alcohol Date*
Marital Status Name of Spouse No. of Children Gender & Age
Mother's Name & Age Deceased (Yes or No) Father's Name & Age Deceased (Yes or No)
Next of Kin Address Contact No.
EDUCATIONAL BACKGROUND
Home Address Home Telephone No.
Next of Kin Name (Emergency) Relationship
Marlins Test Score Test Location Test Licence Code
Highest School Attended Year (e.g 1990 - 1995)
Highest Qualification Attained Major
CERTIFICATE OF COMPETENCY
Description of Certificate Certificate Class Certificate No. Issued Date* Expiry Date* Limitations Applying (if any) Country of Issuance
COURSE ATTENDED &
CERTIFICATES OBTAINED
Description of Certificate Certificate No Issued Date* Expiry Date* Revalidated (Yes or No) Country of Issuance
Watchkeeping COC for Ratings
Personal Survival Techniques (A-VI/1-1)
Basic Safety Training (A-VI/1-1 to 1-4)
Elementary First Aid (A-VI/1-3)
Basic Firefighting (A-VI/1-2)
Survival Craft & Rescue Boat (A-VI/2 para 1-4)
Personal Safety & Social Responsibility (A-VI/1-4)
Medical First Aid On Board (A-VI/4-1)
Fast Rescue Craft (A-VI/2 para 5-8)
Security Awareness Training (A-VI/6-1)
Security Training for Seafarers with Designated Security Duties (A-VI/6)
HUET
BOSIET / FOET
Ship's Crane Operator
H2S
Helicopter Landing Officer (HLO)
Any other certs (please indicate)
SEA SERVICES RECORD AS IN
SEAMAN BOOK. INDICATE
MAXIMUM
MUST BE TRUE and HONEST in SEA SERVICES and Previous RANK - SEA TIME STATED BELOW MUST BE THE SAME WITH SEAMAN BOOK & DP LOGBOOK
Vessel Name Company & Country Type of VesselDP1/DP2/D
P3GRT
Engine
TypeRank BHP/K-WATT
Reason For
Leaving
Signed
On*
Signed
Off*Flag
Type and number of
offshore operations
carried out
Charter & Areas
of Operations
INDICATE SOME ENGINE MODEL
NUMBER.EXAMPLE OF ENGINE MODEL AS BELOW
Remarks
REFERENCES DECLARATION
Name of Company Name of Contact Person Email Contact Number
Date*
I hereby declare that the information furnished above is true to the best of my knowledge.
Signature
FWM 2/23/20167:32 PM
# Form have to be completely filled with information and signed * Dates to be in entered in DD/MM/YY format
A.
B.
C.
D.
E.
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
F. G.
No
1
2
3
4
5
Place of Birth Contact No. 2
Date of Birth* Nationality & Race
APPLICATION FOR THE POSITION OF:
Rec
ent P
hoto in
JPEG
(Com
pulsory
)
CURRICULUM VITAE (CV)
PERSONAL DATA
Name (Exactly As in Passport) Contact No. 1
International Passport No. Passport Expiry Date*
Seaman Book No. Seaman Book Expiry*
Current Salary in USD Expected Salary in USD Date of Availability*
Working Coverall Size Working Shoe Size
Body Weight in KG Height in CM Religion
Medical Certificate Issue Date* Medical Certificate Expiry*
Email Address Skype ID Medical History (if any)
Main Airport Name Drug & Alcohol Date*
Marital Status Name of Spouse No. of Children Gender & Age
Mother's Name & Age Deceased (Yes or No) Father's Name & Age Deceased (Yes or No)
Next of Kin Address Contact No.
EDUCATIONAL BACKGROUND
Home Address Home Telephone No.
Next of Kin Name (Emergency) Relationship
Marlins Test Score Test Location Test Licence Code
Highest School Attended Year (e.g 1990 - 1995)
Highest Qualification Attained Major
CERTIFICATE OF COMPETENCY
Description of Certificate Certificate Class Certificate No. Issued Date* Expiry Date* Limitations Applying (if any) Country of Issuance
Training Couse for Ship's Cook
Certificate of Competency for Cook
Maritime Catering
Food Handling & Hygiene
COURSE ATTENDED &
CERTIFICATES OBTAINED
Description of Certificate Certificate No Issued Date* Expiry Date* Revalidated (Yes or No) Country of Issuance
Any other certificates (please indicate)
Personal Survival Techniques (A-VI/1-1)
Basic Safety Training (A-VI/1-1 to 1-4)
Elementary First Aid (A-VI/1-3)
Basic Firefighting (A-VI/1-2)
Survival Craft & Rescue Boat (A-VI/2 para 1-4)
Personal Safety & Social Responsibility (A-VI/1-4)
Medical First Aid On Board (A-VI/4-1)
Fast Rescue Craft (A-VI/2 para 5-8)
Security Awareness Training (A-VI/6-1)
Security Training for Seafarers with Designated Security Duties (A-VI/6)
HUET
BOSIET / FOET
Any other certs (please indicate)
H2S
BHP/K-WATTReason For
Leaving
Signed
On*
Signed
Off*Flag
Type and number of
offshore operations
carried out
Charter & Areas
of OperationsVessel Name Company & Country Type of Vessel
DP1/DP2/D
P3GRT
Engine
TypeRank
Name of Company Name of Contact Person Email Contact Number
REFERENCES
SEA SERVICES RECORD AS IN
SEAMAN BOOK. INDICATE
MAXIMUM
MUST BE TRUE and HONEST in SEA SERVICES and Previous RANK - SEA TIME STATED BELOW MUST BE THE SAME WITH SEAMAN BOOK & DP LOGBOOK
Signature Date*
I hereby declare that the information furnished above is true to the best of my knowledge.
DECLARATION
FWM 2/23/20167:32 PM