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Application Form Deck Engineering Officers

Section 1 Position

Position Applied for

Lowest Position
Date of Availability

Section 2 Personal Detail

Family name / surname

First Name / Given Name
Date & Place of Birth
Nationality
Permanent Address
Present Adress

PPE Information Safety Shoes Size Coverall Size

Present Contact Number

Fax Number
Mobile Number
Email Address
Nearest Airport

Section 3

Country of Issue USA Visa - Type

Date Issued USA VISA
Expires
Place Issued USA Visa - type
Passport Number USA VISA
Expires
Passport Expires Other Country
Visa
Secondary Passport or Dual Nationality Visa Expires

Section 4 ( hi light as required ) Seamans Book / Discharge Book / Seamans Record Book / CDC
Issued County & Place Date Issued
Number Expiry Date (if
any)

Section 5 Next of Kin this is important information we require Dont ignore it

Full Name / Relationship

Any dependents / Children(incl age)

Address
Contact Numbers

Section 6 STCW95 Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)

Class / Grade/Capacity Issuing Country Certificate No. Date Issued Expiry Details of
Limitations

ALSO ENTER ABOVE DETAILS OF ANY OTHER FLAG STATE CERTIFICATES HELD

Section 7 STCW95 Dangerous Cargo Endorsements

Certificate No. Date Expires Details of Limitations/

Petroleum. Issued Grade
Liquefied Gas.
Liquid Chemicals.

Section 8 STCW95 related Courses Attended and Certificates Obtained

Name of Course / Certificate STCW Code Place Issue Date Cert No Expiry
Date

Personal Survival Techniques

Basic Sea Survival / Training
Fire Prevention & Fire Fighting
Elementary First Aid
Personal Safety & Social Responsibility
Proficiency in Survival Craft & Rescue
Boats
Proficiency in RESCUE CRAFTS
Advanced Fire Fighting
Medical & First Aid
Medical Care
( Ship Captains Medical Course )
Radar & ARPA Simulator Trg-
Management level
Ship Security Officers Course (SSO)
Issued under STCW95
Medical Certificate / HEALTH
Certificate
Drug and Alcohal test certificate
YELLOW FEVER
Bridge Team Management
Bridge Resources Management
Electronic chart Display and
Information System course ( ECDIS )
ISM Code
TANKERS FAMILIARISATION
Advanced Tanker Operations (Chem.)
Advanced Tanker Operations (Oil)
Advanced Tanker Operations (LPG)
INERT GAS
CRUDE OIL WASHING
Tanker Safety ( petroleum )
Tanker Safety ( Chemical )
Tanker Safety ( GAS )
REFRESHER & UPDATING
Other ????
Other ????
Other ????
Other ????
Other ????

L
I
S
Section
T 9 OFFSHORE INDUSTRY COURSES

Please
A enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned
L
L of Course / Certificate
Name APPROVALS Place Issue Date Cert No Expiry

O
BOSIET
T
HUET
H
FOET
E
OFFSHORE MEDICALS
( UK,RNORWAY or NETHERLAND )
Re-Breather training
CStandby vessel crews training
Initial
( ITSO
O)
CAA (Civil Aviation Authorities
U
Helicopter)
R Medical Aider ( AMA )
Advanced
S
E
HLO
MARLINs English Test
IELTS-English TEST SCORE
PMS maintenance system Confirm that you are Familiar with its use ( YES / NO )

DEEP WATER ANCHOR HANDLING EXPERIENCE ENTER DEPTTH IN METERS ???????

DP Maintenance Courses
DP Maintenance Courses

Dynamic Positioning Induction Course

Dynamic Positioning Simulator Course
Dynamic Positioning Operators
CERTIFICATE
Dynamic Positioning Log book Details

Section 10 Hours done with various DP system

SYSTEM DETAILS Approx Hours as SDPO / Approx Days in case Approx Hours as DPO / Approx Days
of Senior ETO / Senior Engineer in case of Junior ETO / Junior
Enginee

KONGSBERG DP2
CONVERTEAM DP3
KONGSBERG DP2

APPROXIMATE Total DP Hours in Various Operations

SAT DIVING CABLE LAYING
AIR DIVING SURVEY
ROV PIPE LAYING
WELL STIMULATION / DRILL SHIP / SEMI SUB
INTERVENTION / ACTIVATION
AHTS PSV
FPSO SHUTTLE TANKER
CONSTRUCTION ROCK DUMPING /
MATTRESSING
CORING TRENCHING
HEAVY LIFT ACCOMMODATION / GANGWAY

Section 11 Medical History

YES NO
Have you ever signed off a ship due medical reason ?
Have you undergone any medical operations in past ?
Have you consulted a doctor during the past 12 months for an illness / Accident
Do you have any health or disability problem now ??

If answer to any of above is YES then give further details below or on a separate sheet

NOTE : The company have STRICT Alcohol and Drug Policy, Which means
ZERO TOLERENCE for alcohol and drugs

Section 12 General

YES NO
Have you ever been the subject of a court of enquiry or involved in a maritime accident
Have you ever had a professional licence suspended or revoked
Have you ever been convicted of any criminal offence?
Have you ever been dismissed

If yes to any of above then please full details below or on separate sheet of paper

Section 13 References (Last Two Recent Employers)

Name of Company
Name Person to be contacted
Address
Tel No Fax
Email

Name of Company
Name Person to be contacted
Address
Tel No Fax
Email

Section 14 Any other information, you wish to add in support of your application

Section 15 Declaration
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
And confirm that All my certificates / Licences are Authentic / SEASERVICE RECORD is ACCURATE / And I confirm
accepting Companies DRUG & ALCOHOL Policy

Signed . Date

Section 16 Record of Sea Service (All Dates to be entered as dd/mm/yy)

Please give full record of sea service STARTING FROM LAST VESSEL FIRST
VESSEL COMPANY Type of DWT or Type of BHP RANK Sign on Sign off
Vessel Engines DATE DATE
And Type
GRT Or DP
(please delete
of as reqd) System
operation
in case of
DP vessels
23.05.2011 Till Now
04.10.2010 27.02.2011
13.08.2010 04.10.2010
08.03.2010 06.08.2010
12.12.2009 07.03.2010
16.01.2009 07.11.2009
22.08.2007 18.07.2008
09.04.2007 27.06.2007
01.03.2006 15.08.2006
14.03.2005 29.09.2005
01.03.2004 11.09.2004
15.05.2001 19.04.2002
04.07.2000 14.04.2001
02.05.1999 27.03.2000
04.07.1998 14.03.1999
20.11.1997 21.06.1998
08.10.1996 15.09.1997
 ADDITIONAL INFORMATION SHEET

VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)

1. DRILLING VESSEL
2.DSV,PSV
3.KABLE
4.ACCOMMODATION BARGE
5.PIPE LAY
MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below)
MINIMUM SALARY PER MONTH in US$ including leave pay ( please enter Only realistic figure ):
Languages Spoken / Written / Understood (1-poor 5-Fluent)
Spoken Written Understood
ENGLISH

DRUG & ALCOHOL POLICY

The company have very strict NO DRUG and ALCOHOL POLICY, Which is required to be complied with
at all times, which means ZERO TOLERENCE on ALCOHOL & DRUG
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight or
commence your travel to join vessel, and Must remain so Until you have completed full contract and
returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL EXPENCES
incurred which will include all your travel and recruiting costs, And your reliefs Travel and recruiting
costs, And Any other costs whatsoever incurred due to your NON-COMPLIANCE will be deducted from
your salary, Which will include but not limited to damage to vessel her equipments and machineries, loss
of charter, and any other costs Directly or indirectly connected with your NON-COMPLIANCE
Sign & CONFIRM ACCEPTANCE OF ABOVE POLICY
FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US- send to us In separate Email
Licence or Certificate of competency, Any tanker endorsements, GMDSS showing expiry date in case of Deck
Officers, Medical Fitness / Examination Certificate, Passport Main page, Seaman book or Discharge book Main
pages, In case of DPO DPO Cert, DP LOG Pages
FOLLOWING ADDITIONAL DOCUMENTS will ALSO BE REQUIRED Send to us in separate email
All short courses certificates ( STCW95 ), SSO certificate, Last 3-5 years ships entries in Discharge book or Seaman
book, Certificate of Equivelant Competency from other flag states