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830a Application Form

Rank / Position Applied

Last Name

First Name

Middle Name Passport Photo

Residential Address

Civil Status Mobile Phone Number

Phone (Land line) Other Contact Number

Email Address Name of School

Highest Education
Year Attended (From-To)
Attainment

Date issued
Seaman’s Book Number
Expiry Date

Date Issued
Passport Number
Expiry Date

DECLARATION

I certify that the above information and attached sea service record are true and accurate; and that any false
information would lead to the nullity and denial of this application.

That all Certificates of Competence or Licenses presented have never been revoked and/or suspended.
I agree that during this application process, I will be subjected to a computer based Professional and English
Language assessment test. The results of which form part of this application.
I agree that previous employers may be contacted for information concerning my employment record and hereby
release them from any liability and confidentiality in providing such information.

In compliance with the Data Privacy Act of 2012 (RA 10173), I agree that ALL information regarding myself may
be shared for hiring / processing and documentation purposes with the principal and all internal interested parties,
Philippine Government Agencies (e.g. POEA, OWWA, DFA, MARINA, SSS) and other external interested parties
(e.g. AMOSUP, P&I Clubs and Correspondents, HMO, Flag State Authorities, Medical Assessment and
Diagnostic Centers).

Signature over printed name Date

ERS-Form 830a | 12 April 2018 Rev: 00


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830a Application Form

Sea Service Record


(most recent vessel first)

Vessel’s M.E.
DWT Signed Signed No.
Foreign Local Rank Name Type of Trade Make Nat. of Nat. of Cause of
& on off of
Principal Agency Served & vessel Route & Officers Ratings Discharge
GRT (dd/mm/yy) (dd/mm/yy) months
Flag KW

ERS-Form 830a | 12 April 2018 Rev: 00

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