Documente Academic
Documente Profesional
Documente Cultură
7 Correspondence Address
& Contact Details : City State Country Zip Code
STD Code Res. Fax: Mobile: Email
10 Name Relationship
Next of Kin - [ Name ,
Address & Contact
City
Details]
State Country Zip Code
Std. Code Res. Fax: Mobile: Email
11 Name
Emergency Address
[If family onboard] City
State Country Zip Code
STD Code Res. Fax: Mobile: Email
Note: Details of any more courses / certificates other than the above may be included below in box No. 18 - [SUMMARY]
PREVIOUS SEA EXP. [ Datewise upto 10 previous vessels in ascending order ] ie : End with your last vessel served
Engine Manning Agts /
16 Vessel Name Flag Type Dwt GRT
Type
Bhp
Owners Name
Rank From To UMS TEUs
REFERENCES:
19 Title Name Company Name Phone Number
A
Address
A
B
LANGUAGES
20 LANGUAGE Spoken Written Read OTHER [specify] Spoken Written Read
ENGLISH
PHYSICAL DECLARATION
21 VISION Excellent Good Poor HEARING Normal Poor Nil
With Glasses Right Ear
Without Glasses Left Ear
Height (cms) Hair [colour] Identification Mark on body [if any]
Weight (kgs) Eyes [colour]
a Are you involved in any marine accident/investigations? [Collision/Grounding/Fire/Pollution]? If yes please give details
b Did you suffer any accident which rendered you temporarily and / or partially disabled ? If yes please give details.
d Did you suffer , or do you presently suffer from any diseases likely to render you unfit for sea service or likely
to endager the health of other persons onboard ?
27 DECLARATION
I certify that the details given by me in filling up this form are true, complete, and correct to best of my knowledge and belief. I
understand that any misrepresentation or material omission made in this application form or other documents submitted to West
Asia Maritime Ltd may renders me liable for termination or dismissal.
Good
Satisfactory
Poor