OM 4.3.
Application Form
Please use additional sheets if required
1 Personal Details
Rank Applied For: Agency:
Name: first middle family
Address:
Photo
Email: Tel:
Mobile: Other:
Nationality: Religion:
Date of Birth: Place of Birth:
2 Family Details
Married: No Yes If yes, Wife’s Name: Date Married:
Wife’s Place / DOB: Wife’s PP No:
Date Issued: Place Issued: Date Expires:
No. of Children: Please give their names and dates of birth.
Name DOB 3.
1. 4.
2. 5.
Full Name of Next of Kin: Relationship:
Address:
Tel: Mobile: Email:
3 Document Details
Document Number Place/ Country Issued Date Issued Date Expires
National Passport
Seaman’s Book
C of C State Med
4 Certificate of Competency
Max. Unrestricted Grade Place/ Country Issued Date Issued Date expires
C of C
GMDSS-GOC
-ROC
5 Tanker Endorsements (DCE)
Level Place/ Country Issued Date Issued Date expires
Oil
Gas
Chemical
6 Qualifications (General & Professional)
From To Qualification Subjects College Place
Computer Proficiency (Word,
Excel)
Additional
Language, specify
Skills
7 Short Training Courses Attended
Rev. 00 Date: 01 Mar 09 Retention Period: Indefinite Page 1 of 2
OM 4.3.1
Place of Date of Place of Date of
Course Course (please specify)
Issue Issue Issue Issue
Shipboard Safety Officer Oil Tanker Familiarization
Ship Security Officer Gas Tanker Familiarization
Bridge Team Management Advanced Oil Tanker Course
ECDIS Advanced Gas Tanker Course
Ship Handling Simulator Prof. [Link] / fast rescue boats
Risk Assessment & accident investing.
Liquid Cargo Simulator course
Liquid Gas Simulator Course
Pers. in charge of Med Care
Adv Fire Fighting / SBFF
8 Sea Service Record for Last 5 Years (Last Service First)
Period DCE Vessel Main Engine
Rank C of C Company
From To level Name Type DWT Name HP
Shore Service: Period: Position:
Nature of Employment: Employer:
9 Additional Information
Have you ever been in a ship involved in an accident? Yes No
If yes, when, and in what capacity were you serving at the time?
Was a court of Enquiry held, were you held in any way to blame?
Has your Certificate ever been suspended? Yes No
If yes, state dates of suspension? From: to:
10 Reasons for Application
State why you wish to leave your present employment.
You may add here anything further you wish to in support
of your application.
May we approach your present employer for a reference? Yes No
If yes, give contact details:
What notice do you require to attend an interview?
What date are you available for sea service?
I declare that the information provided here is true as on the date.
I have attached copies of all the documents supporting information in blocks 2 to 8 inclusive .
Applicant’s Signature: _________________ Date: Agency Signature: ________________
Send to: Copy to:
Rev. 00 Date: 01 Mar 09 Retention Period: Indefinite Page 2 of 2