ADAMSON (PHIL.) INC.

SEAMAN'S INFORMATION SHEET

This application is free of charge, boarded seaman are not required to pay any recruitment fee ANSWER ALL QUESTIONS COMPLETELY

GENERAL INFORMATION
POSITION APPLIED FOR: NAME OF APPLICANT:
(Last Name)

APPLICATION DATE: (1ST CHOICE) (2ND CHOICE)

(First Name) (Middle Name)

HOME ADDRESS: PROVINCIAL ADDRESS: DATE OF BIRTH: CIVIL STATUS: HEIGHT: PHILHEALTH NO.: FATHER'S NAME: WEIGHT: BIRTH PLACE: NAME OF SPOUSE: SSS NO.: PAG-IBIG NO.: MOTHER'S NAME:
NAME OF SCHOOL DEGREE OBTAINED

TEL. NO.: TEL. NO.:

AGE:
RELIGION: TIN NO.:

EDUCATIONAL ATTAINMENT
COURSE TAKEN PRIMARY SECONDARY COLLEGE VOCATIONAL INCLUSIVE DATES

LANGUAGE SPOKEN:

DOCUMENTS
SEAMAN'S BOOK PASSPORT NO. US VISA SRC NO. DATE ISSUED DATE ISSUED DATE ISSUED DATE ISSUED VALIDITY: VALIDITY: VALIDITY: POSITION: PLACE ISSUED: PLACE ISSUED: PLACE ISSUED: PLACE ISSUED:

LICENSES/CERTIFICATE
COUNTRY PHILIPPINES STCW ENDORSEMENT CERT. NO. CERT. OF COMPETENCY (COC) NO. MALTA GENERAL OPERATOR CERT. (GOC) FOR RATINGS COC NO. OTHERS CYPRUS GRADE NUMBER ISSUED/EXPIRY COUNTRY LIBERIAN GRADE NUMBER ISSUED/EXPIRY

REFERENCE PLEASE GIVE THREE (3) REFERENCES WE CAN CONTACT: NAME 1.) 2.) 3.) NAME OF CHILDREN/DEPENDENTS BELOW 18 YEARS OLD NAME DATE OF BIRTH AGE ADDRESS CONTACT NO.

FOR OFFICE USE ONLY

VESSEL SHIP CO. EX CREW

POSITION SALARY/OT NEW HIRE

PERSON REMARKS

TELEPHONE VERIFICATION DATE AGENCY

1 1/2 X 1 1/2 PHOTO MUST BE ATTACHED

Revised 09/08

PREVIOUS SEA SERVICE

NAME OF VESSEL TYPE RANK DATE SIGN ON DATE SIGN OFF NO. OF MONTHS LOCAL AGENT SHIP OWNERS NAME GRT CAUSE OF DISCHARGE REMARK

TRAINING CERTIFICATES
FOR RATINGS BASIC SAFETY COURSE (BSC) PERSONAL SAFETY AND SOCIAL RESPONSIBILITY (PSSR) PROFICIENCY IN SURVIVAL CRAFT & RESCUE BOAT(PSCRB) ADVANCE FIRE FIGHTING(AFF) HUMAN RELATION MARPOL I MARPOL II SHIP SECURITY AWARENESS (SSA) DECK WATCHKEEPING(DWK) ENGING WATCHKEEPING(EWK) FOR TANKER VESSELS GENERAL TANKER FAMILIARIZATION(GTF) SHORE-BASED FIRE FIGHTING(SBFF) SPECIALIZED TRAINING IN OIL TANKER(STOT) SPECIALIZED TRAINING IN CHEMICAL TANKER (STCT) NAC CERTIFICATES BASIC SAFETY COURSE (BSC) PROFICIENCY IN SURVIVAL CRAFT & RESCUE BOAT(PSCRB) ADVANCE FIRE FIGHTING(AFF) GENERAL TANKER FAMILIARIZATION(GTF) SPECIALIZED TRAINING IN OIL TANKER(STOT) MEDICAL EMERGENCY FIRST-AID(MEFA) ALLOTMENT DETAILS: NAME OF ALLOTEE ADDRESS AMOUNT IN WORDS : : :

CERTIFICATE NO.

DATE
ISSUED FOR OFFICERS: MEDICAL EMERGENCY FIRST-AID(MEFA) MEDICAL CARE (MECA) ECDIS SHIP SIMULATOR & BRIDGE TEAMWORK(SSBT) RADAR SIMULATOR COURSE(RSC) BRIDGE RESOURCE MANAGEMENT(BRM) ENGINE ROOM SIMULATOR (ERS) INMARSAT ENGINE RESOURCE MANAGEMENT(ERM) BASIC COMPUTER SHIP SECURITY OFFICER(SSO) COW/IGS RADAR NAVIGATION/RADAR SIMULATOR ARPA/ROC/INMARSAT INTERNATIONAL SAFETY MANAGEMENT(ISM) GMDSS HAZMAT FOR STEWARD DEPT. MESSMAN COURSE SHIPBOARD CULINARY COURSE OTHER CERTIFICATES: INTERNATIONAL/SPEC. OTHER CERTIFICATES: COOKING CATERING MANAGEMENT

CERTIFICATE NO.

DATE
ISSUED

RELATIONSHIP: _____________________ USD : ______________________ ACCOUNT NO.: _____________________

NAME OF BANK/BRACH :

I, HEREBY CERTIFY THAT THE INFORMATION WRITTEN IN THIS APPLICATION IS TRUE AND CORRECT & THE BEST OF MY KNOWLEDGE AND BELIEF THAT ANY MISREPRESENTATION HEREIN WILL BE GROUND FOR NON ACCEPTANCE AND/OR DISMISSAL FOR THE JOB APPLIED FOR AND/OR DISMISSAL FROM THE EMPLOYMENT IF ALREADY EMPLOYED.

Applicant's Name/Signature

Revised 09/08