CMA SHIPS Singapore OPERATIONS MANUAL SECTION 3
Ref: Crew/Form/01a Version: 01/07/2015 PAGE 1 of 1
TITLE: APPLICATION FORM
APPLICATION FORM ATTACH
RECENT
PHOTO
CMA Ships Ukraine
Position applied for:
Type of vessel:
Availabibity date:
Are you responding to a media advertisement? YES/NO
If YES, please state which one
Are you applying upon personal or professional recommendation? YES/NO
If YES, please state who
Surname: First name:
Other names Known as Nationality:
Place of birth: Date of Birth: Age: Male Female
Passport
Number Place of issue Date of issue Date of expiry Issuing Authority
Visas
Type Number Place of issue Date of issue Date of expiry
C1/D (USA)
C1 (USA)
D (USA)
Australia Entry visa
MCV (Australia)
Schengen
Education Background
School / College From To Highest qualification attained
Personal details
Full address:
Postal code: Country:
E-mail: Skype id:
Home tel number:
Mobile phone:
Domestic Airport International Airport
Marital status:
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Full name of Next of Kin: Relationship
Address of Next of Kin
if different from above
Phone
if different from above
2/9
Dependents
Name Date of birth Age Gender Relationship
Person to contact in case of emergency
Name: Relationship
Address:
Phone number: Mobile number:
National Seaman's Book
Number Place of issue Date of issue Date of expiry Issuing Authority
National Certificate of Competency (COC)- Licences
Issuing
Grade Number Date of issue Date of expiry Place of Issue Date revalidated Date expiry
Authority
National GMDSS & Endorsement
Issuing Authority Number Date of issue Date of expiry Place of Issue
Odessa
Medical Fitness Certificate
Type Date of issue Date of Expiry
Yellow Fever Vaccination
Date of Issue Date of Expiry
Foreign languages other than English
Language Level:
Beginner Intermediate Advanced
English
Medical History
Have you ever signed off from
Yes / No If yes give details
a ship due to medical reasons?
Name of vessel Date of Occurrence
Brief description of Illness or Injury
Other personal details
Height: Weight: Colour of Hair:
Colour of eyes: Safety shoes size: Boiler suit size:
Uniform Shirt size: Uniform Trousers size:
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Details of other Marine courses
IMO model
Type of Marine Course Reference- Regulation Number Date of issue Date of expiry
course
1.19 - 1.20 1.13 - STCW Reg.
Basic Training 1.21 A-VI/1-1 to A-VI/1-4
Personal Survival STCW Reg. A-VI/1-1
1.19
Techniques
BASIC TRAINING
STCW Reg A-VI/1-2
Basic Fire Fighting 1.20
STCW Reg A-VI/1-3
Elementary First Aid 1.13
Personal Safety & Social STCW Reg A-VI/1-4
Responsibilities (Human 1.21
Relationship)
Proficiency in survival craft & Rescue STCW Reg A-VI/2 par 1.3
Boats
1.23
STCW Reg A-VI/3
Advanced Fire Fighting 2.03
STCW Reg A-VI/4-1
Medical First Aid 1.14
STCW Reg A-VI/4-2 par 2
Medical Care 1.15
STCW Reg II/2
ROP 1.08
STCW Reg II/1
ARPA / NCC 1.07
Radar Simulator
STCW Reg II/1 par.2.5
ECDIS 1.27
US 49 CFR 172.700-
HAZ MAT
172.204
STCW Reg
Ship simulator bridge teamwork 1.22
II/1
BTM / ETM
STCW Reg VI/5 / ISPS
Ship Security Officer (SSO)
Code
BASSnet
STCW Reg II/1 & II/2
Ship handling & manoeuvring
STCW Reg VIII/2 US33CFR
Bridge resource management
157.415
Loading software (name it)
Large Vessel Handling Simulator / CMA CGM
Engine Room Simulator
Indos Number
Upgradation Course
Revalidation Course for renewal of CoC
High Voltage Training
Reefer Training
Engine Maker’s Training
Crane Manufactures training
ISPS code
Vessel security training course
IMO Assembly Res
Ship Safety Officer
A741(18)
UK MCA
ISF Marlins English test
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Flag State Documents
Document Grade Number Place of Issue Date of Issue Date Expiry
Malta:
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Employment history (at least the last 5 years)
Vessel * Company Manning Agent Trading area Vesse Flag DWT / TEU Year Main Engine Position Sign on Sign off date Total Reaso
l type built date mm/dd n for
** Make Type KW
leaving
***
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
00/00
* or industry sector if ashore
** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off
*** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract
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Summary of Experiences (in number of years)
Years Bulk
Container Tanker Roro others (Please state)
as/ on carrier
Master -
C/E
C/O - 2/E
2/O - 3/E
3/O - 4/E
E/O
Total
Years Sulzer Sulzer SEMT Steam
B&W MAN others
as/ on RTA RND Pielstick Turbine
C/E
2/E
3/E
4/E
E/O
Total
References
Do you have any objection if we will contact your last employers for
Yes/No
reference?
If YES please specify why:
If NO please specify below:
employer
Name of company
Name of person to
contact
Address
Tel number
Please list two contactable referees or past employers
Name of company
Name of person to
contact
Address
Tel number
Name of company
Name of person to
contact
Address
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Tel number
8/9
Bank details
Bank
Sort code:
name:
Branch Swift name
name IBAN number:
Address:
Account
Account
name/
number:
Title
I hereby affirm that all the information provided by me in this application is true and correct to
the best of my knowledge and belief; further, that no Certificate of Competency or License
issued to me has ever been revoked or suspended. I also certify that my medical history
contained abocve is true and any false statement or undisclosed material information about
past illness or injury will disqualify me from any employment benefits and claims.
Date_____________
___ Signature_______________________
* The company may contact my previous employer for references.
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