PHOTO

APPLICATION FORM
1

Position

YES

Position applied for:

Are you willing to accept any other positions?
Readiness From
2

If YES, which positions would you consider?

Last drawn Wages

Personal details
Last Name(as per passport)
Name:
Date/place of birth:

Height in cms.

Weight in Kgs
Color of Hair

Boiler suit size

Food Habit
Strictly Veg
Permanent Address:

Post code:

Mobile No.:
(91) () (Number)

First Name(as per passport)

Nationality:
Color of eyes
Shoe size

No.:
E-Mail Id:

(91) (Area Code) (Number)

Education Background
Name

School

From Year

To Year

Highest Qualification Attained

College

Pre Sea Training

Other Qualifications

Identity documents
DOCUMENT
Passport:
Seamans book:

NUMBER
ISSUED
PLACE
EXPIRY(dd/mm/yyyy)

Yellow Fever
YES
LOT NO.

Date of Expiry

Do you hold a US Visa C1?

YES
Date of Issue

Date of expiry
Do you hold a US Visa D?
YES
Date of Issue

Date of expiry
Do you hold Australian MCV
YES
Date of Issue

Date of expiry
Have you been rejected for any visa applied for?
YES If YES, please state the country and reasons

COUNTRY
National
National
Bahamian
Liberian
Panamanian
Other -Norway

Family details

Next Of Kin
Relationship
Last Name(as per passport)
Name:

Address:

First Name(as per passport)

Contact telephone numbers:

Marital Status:

Names of Children

1st.

(91) (Area Code) (Number)

Date of Birth of Spouse

Sex
MALE
MALE
MALE

2nd

Post code:
(91) (Area Code) (Number)

Marriage Date :
Date of Birth( DD/MM/YYYY)
2004

WSM GLOBAL/MA/101

Rev 0 Dated 01/Aug/2010

National Certificate of Competency (Highest certificate of competency held)

Class/Grade

GMDSS
GMDSS ENDRS.

6a

Issuing Country

Certificate No.

Date Issued

Place Issued

Valid Until

National Dangerous Cargo Endorsements

Petroleum
Liquefied Gas
Chemicals
7

Endorsement Type

Certificate No.

Management
Management
Management

Date Issued

Place Issued

Valid Until

Flag State Equivalent Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)
Class

7a

Issuing Country
Liberia
Panama
Bahamas

Certificate No.

Date Issued

Place Issued

Valid Until

Flag State Equivalent Dangerous Cargo Endorsements (Issued by countries other than in Section 6a)
Country/Type

Certificate No.

Date Issued

Place Issued

Valid Until

Certificates ( STCW and Value added)

CN Code
158
157
160
PSSR
140
151
160
156
164
149
150
161
166
168
169
153
154
155
BTM
BERM
SMSC
LCHS
SSO
6GWC
6GWF
EDIS

Course
Personal Survival Techniques
Basic Fire Fighting
Elementary First Aid
Human Relations PSSR
Watch Keeping Certificate Deck / Eng
Proficiency In Survival Craft - PSCRB
Medical First Aid
Advance Fire Fighting
Ship Masters Medical Care
Radar Observer
Radar Simulator
ARPA
Oil Tanker Familiarization
Chemical Tanker Familiarization
Gas Tanker Familiarization
Adv. Oil Tanker Course
Adv. Chemical Tanker Course
Adv. LPG Tanker Course
Bridge Team Management
BRM / VRM / BERM / ERM
Ship Manoeuvre Simulator
Liq. Cargo Handling Simulator
Ship Security Officer
6 G Welding For Fitter
6G Welding for Fitter with Class Cert.
ECDIS

Institution

Place

Date

WSM GLOBAL/MA/101

Cert. No.

Rev 0 Dated 01/Aug/2010

VESSEL NAME

COMPANY#

VESSEL
TYPE

FLAG

D.W.T.

MAIN ENGINE##

G.R.T.

B.H.P.

RANK

SIGN ON
DATE
DD/MM/YYYY

SIGN OFF
DATE

SEATIME

Make

Type

Y-M-D

##

Please ensure that the full name and address of your immediate past employer is entered in section 11
applicants only

WSM GLOBAL/MA/101

DD/MM/YYYY

Required for engineer

Rev 0 Dated 01/Aug/2010

10

Medical history
Have you ever signed off a ship due to medical reasons?
Have you undergone any operation in the past?
Have you consulted a doctor during the last 12 months for an illness/accident?
Do you have any health or disability problems now?

YES
YES
YES
YES

(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

11

General
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?
Do you have any Criminal record or have any investigation is going on

YES
YES
NO

(If YES, please give full details and attach a separate page if necessary)

12

References (Please give the name and address of your current or immediate past employer)
Name of company
Name of person to contact
Address
No.

12a

() (Area Code) (Number)

Post Code:
() (Area Code) (Number)

References (Please list two contactable referees or past employers in addition to Section 11)
Name of company
Name of person to contact
Address
No.

13

() (Area Code) (Number)

Post Code:
() (Area Code) (Number)

Automatic review
If immediate employment is not available do you wish to be considered for future vacancies?
If YES, please give any alternative contact details not shown in Section 2

YES

14

Declaration
I hereby declare that the above particulars are true and authorise you to contact the referees listed above.

Date:

( dd/mm/yyyy)

Name/Signature

WSM GLOBAL/MA/101

Rev 0 Dated 01/Aug/2010