C
Application For Employment
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 1 of 5
Photograph
Surname
Middle Name
First Name
Nationality
Date of Birth
Place of Birth
Permanent Address:
Present Address:
Post code:
Phone: +
Post Code:
Phone: +
Email:
Date of
Issue
Mobile No:
Date of
Expiry
ECNR
Blank Pages
Passport No
Yes/No
Yes/No
U.S. VISA
MUI/Union Membership
No:
Seamans Book
(CDC)
Indian
Liberian
Panamanian
Marshal Islands
IOM
Bermuda
INDOS No :
Others
Number
Place of
Issue
Date of Issue
Place of
Issue
Expiry
Date
Remark
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 2 of 5
Grade
Indian
U.K.
Singapore
Liberian
Panamanian
Marshal Islands
IOM
Bermuda
Others
Dangerous Cargo
Endorsements
Oil
Chemical
Liquefied Gas
Number
Grade/ Level
Date of
Issue
Number
Place of
Issue
Date of
Issue
Date of
Expiry
Place of
Issue
D.O.E
Data
Wife
Child
M/F
Child
M/F
Child
M/F
* Tick
Valid
________________ Kg
Shoe Size
Name
D.O.B
Passport D.O.I
No
Place of
Issue
Visa
USA
UK
Brazil
Australia
D.O.E
ECNR
(Yes/No)
Number
Date of
Issue
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 3 of 5
Date of
Expiry
Issued
by
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 4 of 5
From
To
Type of Degree
To
Type of Degree
Title
Yes
No
Phone No.
I hereby affirm that all this information provided by me in this application is true and
correct to the best of my knowledge and belief; further, that no Certificate of
competency or Licence issued to me has ever been Revoked or Suspended. I also
certify that any false statement or undisclosed Material information about the past will
disqualify me from any employment benefits and claims.
Date___________
FORM No:QS:10A
Rev 00
Date of Issue: 02/04
Page 5 of 5
Name of
Vessel
Type
1
2
3
4
5
6
7
8
9
10
11
12
DWT
BHP
Engine type
UMS
Y/N
Rank
From
To
Total
MM/DD
Reason
for
S/OFF