Sei sulla pagina 1di 7

Position Applied

for

Date
Filed

Photo
PERSONAL DATA
Surname

First Name

Middle Name

Maiden Name
(for female married
applicant)

Nationality

Date of Birth

Place of Birth

Height

Weight

(mm/dd/yyyy)

Preferred Nickname

Shoe size

SSS No.

PhilHealth No.

Civil Status
Singl
Marrie
e
d
Permanent Address

Separate
d

Widow/er

Email address
PAG-IBIG No.
Sex
Male

Separated

Female

Contact Address

City
Country
Contact No.

City
Country
Contact No.

FAMILY DETAILS
Name

Se
x

Date of Birth
(mm/dd/yyyy)

Place of Birth

Spouse
(please indicate Maiden
Name)
(if deceased, please
indicate)

Father
(if deceased, please
indicate)

Mother
(please indicate Maiden
Name)
(if deceased, please
indicate)

Child/Children

Person to notify in case of emergency


Name:
Address:

Relationship:
Contact Number:

EDUCATIONAL BACKGROUND
Level

School

Highest
Degree Earned
(Course)

Date
From

To

(mm/dd/yyyy)

(mm/dd/yyyy)

Place
QSF 98/2010/REV. 03

Collegiate
Secondary

QSF 98/2010/REV. 03

RECORD BOOKS
Date

Document No.

Issuing Authority

Issued

Expiry

(mm/dd/yyyy)

(mm/dd/yyyy)

Passport (PH)
Seamans Book (PH)
SRC (PH)
US Visa
Flag State Seamans
Book
*Flag State 1. Bahamas 2. Marshall Islands 3. Liberian 4. Singapore 5. Others please specify
*Issuing Authority 1.MARINA 2. DFA 3. US Embassy 4. Bahamas Maritime 5. Marshall Islands Authority 6. Others please specify

A. Have you ever been denied of any visa?


If yes, please provide following details:
Country
Date of Refusal

Ye
s

N
o

Ye
s

N
o

Reason for refusal

B. Have you ever been deported?


If yes, please provide following details:
Country
Date of deportation

Reason for deportation

TRAINING COURSES
Training Name

Document No.

Issued Date
(mm/dd/yyyy
)

Training
Center

With COP
(NAC)?

Training
Center

With COP
(NAC)?

Issued
Date
(mm/dd/yyy
y)

Basic Safety Course


Proficiency in Survival
Craft and Rescue Boat
Advanced Firefighting
General Tanker
Familiarization
Shore-based firefighting
Crowd Management
Crisis Management
Watchkeeping

OTHER TRAINING COURSES


Training Name

Document No.

Issued Date
(mm/dd/yyyy
)

Issued
Date
(mm/dd/yyy
y)

Basic Training -

LICENSE / ENDORSEMENT
Grade

Document No.

Date
Issued

Expiry

Issuing
Authority

OIC NAV. WATCH (PH)


OIC ENG WATCH (PH)
OIC NAV. WATCH (Flag
State)
OIC ENG WATCH (Flag
QSF 98/2010/REV. 03

State)
GOC (PH)
GOC (Flag State)
*Flag State 1. Bahamas 2. Marshall Islands 3. Liberian 4. Singapore 5. Others please specify
*Issuing Authority 1.PRC 2. Bahamas Maritime 3. Marshall Islands Authority 4. Others please specify

QSF 98/2010/REV. 03

PREVIOUS EMPLOYMENT

Please complete below with details of your previous employment for the past ten (10) years.

SEA EXPERIENCE (with recent on top line)


Date
Rank

Vessel

From

Use only the following abbreviation for vessel types:


GCD General Cargo
B/C Bulk Carrier
OBO Ore / Bulk / Oil Carriers
TNC Tanker (Crude)
GAS LPG / LNG Gas Carriers
CHM Chemical Carriers
OSV Off Shore Supply Vessel
DRG - Dredgers

To

CON Cellular Container


TNP Tanker (Product)
PAS Passenger Ship
SRV Survey Vessel

GRT

Engine
Make

Vesse
l
Type

MLP Multipurpose
TNV VLCC / ULCC
R/O Ro/Ro Carriers
LOG Log / Timber

Indicate
Foreign
Employer or
Agency

Reason for
leaving

O/O Ore / Oil Carrier


TNS Tanker (Storage)
C/S Car Ship
RFR Reefer

LAND BASED EXPERIENCE (with recent on top line)


Position

Employer

Date
From

To

Address of
Employer

Contact No.

Immediate
Supervisor

Salary

Reason for
leaving

QSF 98/2010/REV. 03

MEDICAL HISTORY

It is important that all illness other than minor afflictions should be stated. The Company is entitled to refuse
any claim treatment, cost or any other benefits if a complete statement of all previous illness has not been
given.
A. Have you ever signed off a ship due to medical reasons?
Yes
No
If yes, please provide following details:
Name of vessel
Date of occurrence
Place of occurrence
Brief description of illness / injury / accident

B. Have you ever undergone any operation in the past?


If yes, please provide following details:
Details of operation
Date
Period of disability

Yes

No
Present condition

C. For what illness or accident have you consulted a doctor during the last 12 months?
If yes, please provide following details:
Details of illness
Date
Therapy / Treatment

D. Do you
conditions?

have

any

of

the

following

Ye
s

No

Hypertension
Diabetes
HEPA A or B
Asthma
E. Are you a smoker

Ye
s

No

REFERENCES

Please give references from two recent employers who may we contact for references
Reference 1

Reference 2

Name of Company
Name of person to
contact
Address
Country
Phone

Other Information
A. Do you have any relatives working with us at present
If yes, please provide following details
Name of Crew
Position and Principal

B. Have you ever applied for a job with us before?


If yes, please provide following details
When
Position

Yes

No

Relationship

Yes

No

I hereby declare that the above, including my Medical History is true.


Plac
e

Dat
e

Signatur
e
QSF 98/2010/REV. 03

FOR GALLEY APPLICANTS ONLY


Give a brief description of your duties as mentioned in the Previous Employment part of this application form.

Rank / Vessel

From

(mm/dd/yyy
y)

Land / Sea Experience (with recent on top line)


Date
To
Duties
/
(mm dd/yyyy)

QSF 98/2010/REV. 03

Potrebbero piacerti anche