Application Form

Application Form
 




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English Level
Position : *     Date Avilable : *
Have you worked on ships before? Yes No  (If yes,) Last position : Last ship :
Have you ever been convicted of a felony or a first-degree misdemeanor ? Yes No
First Name : * Last Name : * Date of Birth : * Sex :  *
Place of Birth: Marital Status:    Nationality: * Weight : kg  Height:
Address : Tel. *
Contact Person in Emergency : Relationship : Tel.
 
Types Number Country Place of Issue Issue Date
(dd/mm/yy)		 Expiry Date
(dd/mm/yy)
ID No.
Passport
Seaman Book
Visa
 
School/College (Name & Address) No. of Year(s) From To Highest Qualification Attained
Military Service (Check Yes or No)   Yes No
If yes, what branch ?  
 
Course Institution(s) Issuing Place & Country Certificate No. Date Issue
(dd/mm/yy)
 
Do you have now or have you had ? (Check Yes or No)
Diabetes: Yes No   Back Trouble: Yes No   Stomach Trouble : Yes No   High Blood Pressure: Yes No   Hernia: Yes No
Heart Trouble: Yes No   Defective Hearing: Yes No   Leg Trouble: Yes No   Defective Sight: Yes No
Have you ever signed off a ship due to medical reasons ? Yes No
Have you undergone any operation in the past ? Yes No
Have you consulted a doctor during the last 12 months for an illness/accident ?
 Yes No
Do you have any health or disability problems now ?
 Yes No
If the answer(s) is YES to any of the above, please give full details below.
 
Vessel Company / Hotel
Name & Address 		Department Position Sign on
(dd/mm/yy)		 Sign off
(dd/mm/yy)		 Reason for
Leaving
 
Please give the name and address of your current or immediate past employer ( Not relatives )
Name of Company Name of Contact Person Address Telephone No.
 
I authorize investigation of all statement contained in this application and hereby release all former employers and
agencies named herein from all liability for information regarding me. I understand that misrepresentation or intentional
omission of facts is grounds for refusal to or dismissal. Further, I understand and agree that my employment is for no definite period.
 
I hereby declare that the above particulars are true and authorize you to contact the referees listed above
Should it be necessary, my employment is condition upon a favorable health evaluation.