COMPANY OPERATING MANUAL
APPENDIX COMPANY FORMS
Form Number
: CRW/13
Document Number
Revision Number
Page Number
:
:
:
VMS/COM/01
04
1 of 6
Application
[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]
Individuals Code Number
1. Personal Data
First Name
Syed
Middle Name (s)
Mujtaba Haider
Last Name / Surname
Abdi
Nationality (or current
Citizenship )
Pakistani
Country of Origin
Pakistan
Date of Birth:
29/ 07 / 84
AFFIX YOUR
RECENT
PASSPORT SIZE
PHOTOGRAPH
HERE
Place / City of Birth
Karachi
(DD / MM / YY)
Marital Status1:
Single
Religion:
Male
Islam
Female
1
Select from : Single Married Divorced Common Law Partner Widowed Separated
Gender :
Rank applied for:
Able Seaman
Willing to accept lower rank? Yes
No
Available From (date): 22/ 10 / 12
(DD / MM / YY)
Primary / Permanent Address:
House No.A/47 Sector 14-B Shadman Town No.2 North
Nazimabad Town, Karchi
Alternative / Temporary Address:
Same As Primary Address
Until: / /
City: Karachi
Post Code: 75850
City:
Post Code:
State: Sindh
Nearest Airport : Jinnah
Country : Karachi
State:
Country:
Home Tel: 021-36908310
Phone:
Fax:
Email:
Terminal
Mobile Tel. 0341-8206218
Contact Method :
Collar: cm
Email
Fax
Chest: cm
Specify size as S, M, L, XL, XXL for :
2.
Mobile Phone
Waist: cm
Sweater size:
Home Phone
Inside Leg:
cm
Boilersuit size:
Cap:
Post
cm
Personal ID / Documents / Visa
Type of Document / ID 1
Country of Issue
No.
Date of Issue
(DD / MM / YY)
Issued at (Place)
Valid Until
(DD / MM / YY)
Seamans Book (National)
Pakistan
004940/S
29/ 09 / 05
Karachi
30/ 09 / 15
Passport
Pakistan
AC1077512
02/ 06 / 10
Karachi
02/ 06 / 15
US Visa C1/D
/ /
/ /
Yellow Fever
Pakistan
40142
17/ 12 / 05
Karachi
18/ 12 / 15
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO
Social Security
Number:
Issuing Country
Personal Tax
Number:
Issuing Country:
COMPANY OPERATING MANUAL
APPENDIX COMPANY FORMS
Form Number
: CRW/13
Document Number
Revision Number
Page Number
:
:
:
VMS/COM/01
04
2 of 6
3. Nominee / Next of Kin & Family Details
Relationship1
Full Name of Nominee for compensation in case of fatality:
Gender : Male
Nationality : Pakistan
Female
Syed Muhammad Haider Abdi
Brother
Address: House No.A/47 Sector 14-B Shadman Town No. 2
City: Karachi
Post Code: 75850
Email:
Tel: 021-36908310
Country: Pakistan
Mobile: 0345-2185567
Select From : Spouse Partner Child Parent Grand Parent Other Relative (Please Specify)
Family Data:
Relationship
Spouse / Partner2
Child
Child
Child
Child
Child
F
F
F
First Name
Last Name
Date of Birth
Passport No.
Issued
Place
Valid Until
Indicate type of valid visa
2
Strike out inapplicable item
USA
3
Canada
Brazil
Schengen
UK
Other
Please consider period on board
4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: (Add separate sheet if data exceeds space available.)
Description of Cert /
Course
Country of
Issue
Number
(A)
Reg I
Personal Training Record Reg I/14
Medical Fitness Cert Reg I/9
(B)
Reg VI / 1 Basic Safety Training
Personal Survival Techniques
Pakistan
PSSR 0399
Elementary First Aid
Pakistan
FAC 0404
Fire Fighting & Fire Prevention
Pakistan
BFF 0399
Personal Safety & Social Resp.
Pakistan
PST 0401
(C)
Reg VI / 2 4 Additional Training
Proficiency in Survival Craft & Rescue Boat Pakistan
002969
Fast Rescue Boats
Advanced Fire Fighting
Pakistan
AFF-0681/09
Medical First Aid
Pakistan
0976
Medical Care (Master / C/O)
Date of
Issue
(DD-MMYY)
Date of
Expiry
(DD-MMYY)
Place of
Issue
Issuing Authority /
Body
/ /
/ /
/ /
/ /
08/ 08 / 12
18/ 08 / 12
11/ 08 / 12
15/ 08 / 12
/ /
/ /
/ /
/ /
Karachi
Raconhouse College
Karachi
Raconhouse College
Karachi
Raconhouse College
Karachi
Raconhouse College
06/ 08 / 10
/ /
31/ 03 / 09
25/ 09 / 10
/ /
/ /
/ /
/ /
/ /
/ /
Karachi
Pakistan Marine Acd
Karachi
M.T.I
Karachi
Promety
Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag
state endorsements)
4
25/ 11 / 07
/ /
1028-D
Navigation Watchkeepind
Pakistan
Karachi
M.M.D
Tanker Endorsement At Support Pakistan
10/ 04 / 09
/ /
180/TE/09
Karachi
M.M.D
Level
/ /
/ /
/ /
/ /
/ /
/ /
(D)
/ /
/ /
Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you
(E)
Other mandatory/recommended Certificates / Courses (as applicable)
ARPA (Reg II/1 + Solas)
/ /
/ /
Radar Simulator
English Language
Bridge Team / Resource Mgmnt
Hazmat (US 49CFR)
Shiphandling/ShipManoeuvring
Simulator
Shipboard Security Officer
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
Select as applicable: Passport Seamans Book Seaman Passport Seafarers Identity Document Registration Book National ID Card PAG-IBIG
Housing Insurance Health Insurance Overseas Emp Cert PHL Card Pension Fund Provident Trust Professional Organisation Driving Licence Visa
Vaccination Yellow Fever.
COMPANY OPERATING MANUAL
APPENDIX COMPANY FORMS
Form Number
: CRW/13
Document Number
Revision Number
Page Number
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/ /
/ /
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:
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VMS/COM/01
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COMPANY OPERATING MANUAL
APPENDIX COMPANY FORMS
Form Number
: CRW/13
Description of Cert /
Course
Document Number
Revision Number
Page Number
Country of
Issue
Date of
Issue
(DD-MMYY)
Number
(F)
GMDSS Certificates (including flag state endorsements)
GMDSS (Main Issuing Authority)
GMDSS (Flag State)
GMDSS (Flag State)
GMDSS (Flag State)
GMDSS (Flag State)
GMDSS (Flag State)
/ /
/ /
/ /
/ /
/ /
/ /
Reg V / 1 Special Requirement for Tankers
Level1:
Country
Description
Incharge
of Issue
Level2: Asst.
Endorsement Oil
:
:
:
Date of
Expiry
(DD-MMYY)
/ /
/ /
/ /
/ /
/ /
/ /
VMS/COM/01
04
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Place of
Issue
Issuing Authority /
Body
(G)
(H)
Date of
Issue
(DD-MM/ /
Endorsement Chemical
/ /
Endorsement Gas
/ /
/ /
Number
Place of
Issue
Issuing Authority /
Body
Tanker Familiarisation
(Oil)
Para 1
Tanker Familiarisation
(Chemical)
Para 1
/ /
Tanker Familiarisation
(Gas)
Para 1
/ /
Special Tanker Safety
(Oil)
Para 2
/ /
Special Tanker Safety
(Chemical)
Para 2
/ /
Special Tanker Safety
(Gas)
Para 2
/ /
V/2 and V/3 Special requirement for Passenger / Ro-Ro Passenger Vessels
Vsl Type
Date of
Country of
Place of
Description
Number
-Pax /
Issue
Issue
Issue
RoRoPax
(DD-MM
Crowd Management
/
/
Crisis Mgmnt & Human Behaviour
Pax Safety, Cargo Safety & Hull Integrity
Pax Safety
Familiarisation Training
Safety Training
/ /
/ /
/ /
/ /
/ /
Issuing Authority /
Body
5. Sea Experience : (Last 5 years; Start the listing below with the most recent experience)
A.M.P.T.C
Panama & Shaybah
TNP
28519
47185
B&W
10480
A-B
Date
Date To
From
dd/mm/yy
dd/mm/yy
16/08/09
23/05/10
U.A.S.C
Bahrain & Mayssan
CON
75579
85436
SULZER
62920
A-B
16/05/08
15/11/08
Aqua Gulf
Aqua Trader
GCD
8842
15143
PIELISTIC
5040
O.S
01/07/07
22/10/07
Universal
Aqua Trader
GCD
8842
15143
PIELISTIC
5040
GP-III
25/01/07
30/06/07
Universal
Glory
GCD
8842
15143
PIELISTIC
5040
GP-III
23/12/05
25/01/07
Company
(1)
Flag & Vessel Name
Type
(1)
GRT
DWT
Main Engine
(2)
BHP
Rank
Use only the following abbreviations for vsl types:
B/C
CON
CHM
CH3
DRG
DP
FSH
Bulk Carrier
Cellular Container
Chem Carrier IMO I-II
Chem Carrier IMO III
Dredgers
Dynamic Positioning
Fishing Vsl
FPSO
GCD
HLV
LSH
LIV
LNG
LOG
FloatgProdStorOffldg
General Cargo
Heavy Lift Vsl
Lash
Live Stock Carrier
LNG Carrier
Log/Timber
MLP
MSV
NVL
RIG
OSV
OBO
O/O
Multi-purpose
MultiServiceVessel
Naval Ship
OffShore Oil Rig
OffShore Supply Vsl
Ore/Bulk/OilCarrier
Ore/OilCarrier
PAS
RFG
R/R
PRR
SAL
SRV
SUL
Passenger Ship
Reefer Vessel
Ro/Ro Carrier
RoRo-Pax
Sailing Vsl
Survey Vessel
Self-Unloader
YAT
TNB
TNC
TNP
TNS
TNV
Yacht
Tanker(Bitumen)
Tanker(Crude)
Tanker(Products)
Tanker(Storage)
Tanker(VLCC/ULCC)
COMPANY OPERATING MANUAL
APPENDIX COMPANY FORMS
Form Number
: CRW/13
FSO
(2)
FloatingStorageOffldg
LPG
Document Number
Revision Number
Page Number
LPG Carrier
OTH
Engineers to give make/model of engines, e.g. MAN 14V52/55A or SULZER 5RTA58
Other
TUG
Tug
:
:
:
VMS/COM/01
04
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COMPANY OPERATING MANUAL
APPENDIX COMPANY FORMS
Form Number
: CRW/13
Document Number
Revision Number
Page Number
:
:
:
VMS/COM/01
04
6 of 6
6. Medical History:
Sheet 4
All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed, the
Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured
benefits.
(A)
Blood Type
O+
Have you ever signed off a ship due to medical reasons?
Yes
No
If yes, please provide following details (If space is insufficient, attach additional sheets) :
Name of vessel
Date of occurrence
Place of occurrence
Brief description of illness/injury/accident
(B) Have you undergone any operation in the past?
If yes, please provide following details:
Yes
No
Details of operation
Date
Period of disability
Present condition
(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
Details of illness / accident
Date
Therapy/Treatment
(D) Please give details of any health or disability problem
Details:
7.
Bank Details:
Other Details: (if any)
Bank Name
Address
Account Name
Account No.
Sort Code
8.
General
(A)
Have you ever been denied a foreign visa?
Yes
No
If yes, state which country and reason (if known)
(B) Have you been the subject of a court of enquiry or involved in a maritime accident?
If yes, please attach details
(C) Give details below of two recent employers who we may contact for references:
Yes
No
Name of Company
Name of person to contact
Address
Reference 1
Marine Fleet Management
Jawaid Kamal
205-Shaheen Center, DC-5 Block7, Clifton, Karachi
Reference 2
Mackinnons Mckenzie
Mr.Faisal
Mackinnon Building I.I.Chandrigar Road,
Karachi
Country
Telephone
Pakistan
021-35830951
Pakistan
021-32413041
I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by you and any of your direct or indirect parent or subsidiary or
associated or affiliated companies (V Ships) and your or V Ships principals of personal data about me (including where appropriate data concerning racial or ethnic origin, religious
beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and the outcome of any proceedings
relating thereto) for all purposes related to my application for employment on board vessels managed by V Ships or vessels owned or operated by third parties for whom V Ships is
engaged to provide crew. I understand that this data will be stored in your databases in relation to my actual or potential employment by or through V Ships. Further, I confirm that the
above may involve the transfer of my personal data within V Ships or to third parties worldwide.
Place: Karachi
For Office Use:
Date: 22/10/12
Signature:.
