APPLICATIONFORM (Officers Engineers) DD
APPLICATIONFORM (Officers Engineers) DD
APPLICATIONFORM (Officers Engineers) DD
Present Address
Section 4 ( hi-light as required ) Seaman book / Discharge book / Seaman Record Book / CDC
Issuing Country & Place Date Issued
Number Expiry Date (if any)
Section 5 Next of Kin – this is important information we require- Don’t ignore it
Full Name / Relationship
Any dependents / Children (incl age )
Address
Contact Numbers
Also Enter Above Details of any Other Flag State Certificates (Also List Flag State Endorsements)
Section 8 STCW2010 (STCW78, as amended) related Courses Attended and Certificates Obtained
Name of Course / Certificate STCW Code Place Issue Date Cert No Expiry Date
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L Section 9 OFFSHORE INDUSTRY COURSES
I Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned
S Name of Course / Certificate APPROVAL Place Issue Date Cert No Expiry
T S
A BOSIET / FOET
L HUET
L
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
O Re-Breather training
T
Initial Standby vessel crews training ( ITSO )
H
E CAA (Civil Aviation Authorities – Helicopter)
R Advanced Medical Aider ( AMA )
HLO
C
O HLA
U Hydrogen Sulphide (H2S)
R MARLIN’s English Test Score:
S %
E IELTS-English TEST http://www.ielts.org/test_centre_search/search_results.aspx SCORE
S
PMS maintenance system – Confirm that you are Familiar with its use ( YES / NO )
DP Maintenance Courses
DP Maintenance Courses
HIGH VOLTAGE COURSE
Dynamic Positioning Induction Course
Dynamic Positioning Simulator Course
Dynamic Positioning Operators Full or
CERTIFICATE Limited
(Details of Old Certificate- Before Renewal )
Dynamic Positioning Operators Full or
st
WPIF – M/01 01 November 2017 Rev - 10
Seafarer’s Signature ………………
CERTIFICATE Limited
(Details of New Certificate- After Renewal )
Dynamic Positioning Log book Details
SYSTEM DETAILS Approx Hours as SDPO / Approx Days Approx Hours as DPO / Approx Days in
in case of Senior ETO / Senior Engineer case of Junior ETO / Junior Engineer
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Section 11 Medical History
YES NO
1. Have you ever signed off a ship due medical reason and been hospitalised?
2. Have you ever been signed off the vessel and repatriated due illness?
3. Have you undergone any medical operations in past?
4. Have you consulted a doctor during the past 12 months for an illness / Accident
5. Do you have any health or disability problem now??
6. Any Past Medical Condition – Which May Affect Your Work :- (If Yes Than Please Specify Below)
7. Do you feel healthy and fit to perform the duties of your designated
Position/occupation?
8. Are you allergic to any medications?- If Yes, then please identify below
Allergic to Medications :
9. Are you taking any non-prescription or prescription medications at present?
If yes, please list the medications taken, and the purpose(s) and dosage(s):
NON-PRESCRIPTION MEDICATION:
If answer to any of above is YES then give further details below or on a separate sheet
NOTE : All our clients have STRICT Alcohol and Drug Policy,
Which means ZERO TOLERENCE for alcohol and drugs
Section 12 General
Yes No
Have you ever been involved in a maritime accident, ie grounding, fire, Explosion, Collision.etc
Have you been Rejected by Aramco / Shell or by any other Charter
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
Have you ever been convicted of any criminal offence?
Have you ever been dismissed due any reason
If yes to any of above then please full details below or on separate sheet of paper
Name of company
Name Person to be contacted
Address
Tel No Fax
Email
Name of company
Name Person to be contacted
Address
Tel No Fax
EMAIL
Section 14 Any other information, you wish to add in support of your application
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