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830a Application Form
Last Name
First Name
Residential Address
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That all Certificates of Competence or Licenses presented have never been revoked and/or suspended.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).
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