Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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
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
Ye
s
N
o
Ye
s
N
o
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)
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
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.
Vessel
From
To
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
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
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
Yes
No
Relationship
Yes
No
Dat
e
Signatur
e
QSF 98/2010/REV. 03
Rank / Vessel
From
(mm/dd/yyy
y)
QSF 98/2010/REV. 03