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Officer

Photo
Applied for Rank :
For International Crew

Surname : First Name : Middle Name:

Date of Birth : Place of Birth : Nationality :

Blood Safety Shoe Yellow Fever Last. Med Home town


Height: Weight: Overall Size: Religion
Group: Size Iss.Date Iss.Date Airport

Permanent address : Local address : NOK Details :


Relation :
Address:

Tel :

E mail

Mobile:

Documents Number Place of issue Date of issue Expiry INDOS NO.

Passport

Seaman's Book

US VISA-C1/D

Family Details :
Name D.O.B. P.O.B. Passport No. Date of Issue Place Expiry Nationality

Wife

Children :

Qualifications: Academic Background :


Name of Institution City + country From To Qualification Obtained Grade / Percentage

Pre-Sea Training Institute: From To


Apprenticeship/Jr.Eng. From To

Certificate of Competency
Date of Issuing
Grade Number Expiry Remarks Ok/Others
Issue Country
National C.O.C.

GMDSS

DCE - PET.

DCE- CHEM.

DCE- LPG

ASP Group Page 1 CMWI-605-R0


Equivalent Endorsements :
Seamens
Grade License Identity GMDSS
Documents
Issue STCW'95
Number Issue Date Expiry Number Expiry Number Issue Date Expiry
Date Validity

Cyprus

Marshall Is.

Liberia

Panama

Singapore

Others

Minimum STCW Certificates :


Date Of Place of Name of
Number Expiry Date
Issue Issue institute
Fire Fighting
(FPFF)
Fire Fighting (ADV)

Personal Survival
Tech.
PSC & RB

PSSR

Ship Captain's
Medicare
Medical First Aid

Elementry First Aid

Other STCW Courses


Radar Observer

ARPA

Radar Simulator

RANSCO
Sp.Tanker safety
Pet.
Sp.Tanker Safety
Chem.
Sp.Tanker Safety
-LPG
OTFC

CTFC

GTFC

Other courses
Ship Manov.&
Simulator
Simulator-Engine
Room
LCHS

HAZMAT

BTM

BRM

FRAMO
TKR VETTING
INSPECTION
BULK CARRIER
SAFETY
V.R.M.

ASP Group Page 2 CMWI-605-R0


Certificate Date Of
Course Place of Issue Expiry Date Name of Institute
Number Issue

Practical Experience : Have you experience of the following (Please signify thus 'X')
New Building [ ] Planned Maintenance System [ ]
Steam Turbines Cargo Pumps [ ] (a) Computerised (Specify) [ ]
Engine Driven Cargo pumps [ ] Planned Maintenance System
Cargo Pump type (a) Computerised (Specify) [ ]
a) Centrifugal pumps [ ] (b) Others [ ]
b) Screw pumps [ ] Container (specify TEU) [ ]
c) FRAMO Pump [ ] Reefer container [ ]
Cargo Reefer plant [ ] Reefer Cargo [ ]
Deck crane type Dry dock [ ]
a) Thyrister control [ ] Major repairs [ ]
b) Electrical [ ] Major Fire [ ]
c) Electro hydraulic [ ] Collision [ ]
d) Gantry [ ] Pollution Incident [ ]
Knowledge of ships electrical and
[ ] [ ]
Crude Oil Wash operations electronic system
Knowledge of vessels automation and
[ ] [ ]
Inert Gas System computerized system

Enumerate the different Nationalities you have sailed :

Officers :

Ratings :

Reason for application : State why you wish to leave your present employment:-

Preference for employment on : Tanker or Dry Cargo

May we approach your PRESENT employer for Reference ? Tel no.____________ Name :

May we approach your PAST employer for Reference ? Tel no.________________ Name :

Have you ever had to leave a Company other than voluntarily ?

What date are you available for sea service ?

I hereby affirm that all the information provided by me in this application is true and correcct to the best of
my knowledge and belief; further, that 'no Certificate Of Competency or Licence issued tome has ever been
revoked or suspended.

Date : ________________ Signature : ________________


FOR OFFICIAL USE ONLY.

ASP Group Page 3 CMWI-605-R0


SEA SERVICE (FOR LAST 10 YEARS)
UMS TEU Reason for
Company Vessel Rank Type Y.O.B. Flag DWT/GRT From To BHP Engine Type
(Y/N) Capacity S/off

ASP Group Page 4 CMWI-605-R0