Please Click and Select Appropriate Value From List where highlighted in Yellow

SEAFARER EMPLOYMENT FORM

RPSL-MUM-401 Affix recent
colour photograph
Rank applied for --Select-- INDOS

Available From Emp Code

Last Draw Wages -

Surname Midddle Name Name

Date of Birth Place of Birth Religion Nationality Pan Card Number

--Select-- --Select--

Passport Issue Expiry Issue

Number Date Date Place

National Seamen Book Number Issue Expiry Place

Other Seamen Book Number Issue Expiry Place
Other Seamen Book Number Issue Expiry Place

Valid Visa's
US Visa C1/D Issued Expiry Place
Any other visa Issued Expiry Place

Contact Details
Present Address Permanent Address

Pin Code Pin Code

Mobile Mobile
Land Line Land Line

Email Email
Nearest Domestic Airport : Nearest Intn'l Airport:
 Family details
Marital Status --Select--
Relationship Surname Name DOB Passport Issue Epxiry
--Select--
--Select--
--Select--
--Select--
--Select--
--Select--
Next of Kin Relationship --Select--
Address
Tel : Email :
 FP 01

Affix recent
colour photograph

Name

ard Number

Address
 --Select--
Place of Issue

--Select--
Please Click and Select Appropriate Value From List where highlighted in Yellow

Seafarer Certificate Information

Academic Qualifications
College /Degree University Year Passed

Pre Sea Training

Description Insitute Year Passed

Certificates STCW Reg Grade Number Issued

Certificate of Competency --Select--
Endorsement to Certificate of Competency --Select--
GMDSS (GOC) --Select--
GMDSS Endorsement --Select--
Watchkeeping for Ratings --Select--
Tanker Endorsement --Select--
Chemical Endorsement --Select--
Liquified Gas Endorsement --Select--

STCW Certification STCW Reg MLC 2010 Grade Number Issued

Personal Survival Techniques
Proficiency in Survival Craft and Rescue Boat
Personal Safety and Social Responsibilities
Elementary First Aid
Medical first Aid / Master's Medicare
Yellow Fever
Fire Prevention and Fire Fighting
Advanced Fire Fighting
Oil Tanker Familiarization
Chemical Tanker Familiarization
Gas Tanker Familiarization
Advanced Oil Tanker Safety(TASCO) - Petroleum
Advanced Chem Tanker Safety(CHEMCO)- Chemical
Advanced Gas Tanker Safety(GASCO)- Gas
Radar Observer
Radar Simulator
Automatic Radar Plotting Aids

Other Certification STCW Reg MLC 2010 Grade Number Issued

Ship-Security-Officer
ECDIS ( IMO 1.27)
Liquid-Cargo-Handling-Simulator
Bridge-Team-Management (BTRM / BRM)
Bridge Simulator
Engine-Room-Simulator
Large Ship Handling Course (VLCC / ULCC)
Inert Gas Systems
Crude Oil Washing
HAZMAT-Course
Fast Rescue Boat
Ship Maneuvering Simulator
Revalidation-Course
6G Welding Certificate (Fitter / Welder)
Security Training for Seafarers with Designated Security Duties
Ship Safety Officer
Indian Maritime Legislation course
High Voltage

- Please give details of any other certificates held in the blank rows
Flag Endorsements for National certs STCW Reg Grade Number Issued
Singapore Licence --Select--
Singapore GMDSS --Select--
Singapore Seamens Book --Select--
Panama Licence --Select--
Panama GMDSS --Select--
Panama Seamens book --Select--
Hongkong Flag - Licence --Select--
Hongkong Flag - GMDSS --Select--
Hongkong Flag - Seamens Book --Select--
Malaysian Flag - Licence --Select--
Malaysian Flag - GMDSS --Select--
Malaysian Flag - Seamens Book --Select--
Liberia Licence --Select--
Liberia GMDSS --Select--
Liberian Seamens Book --Select--
 FP 01 - Page 2 of 4

Year Passed Grade /Percent

Year Passed Grade /Percent

Issued Validity Issued at

Issued Validity Issued at

Issued Validity Issued at

Issued Validity Issued at
Details of Sea Service
In chronoligical order - Last vessel first

Company Vessel Year Rank Type Flag

(Owner / Operator) Built
 FP 01 - Page 3 of 4

DWT/GRT From To Tenure Engine Type A/E BHP / KW UMS

Period (Y/N)
Reason for S/off cargo carried Vessel Trading Area
 FP 01 - Page 4 of 4

Deck Officers :
Cargoes Carried :
Trading Pattern :

Engineer Officers :
Type of Machinery :
:

Seafarer Medical history :

Height in Centimetres cms Weight in Kg's Kg's

Boiler Suit Size Safety Shoes

Shirt Size Trouser Size (Saloon Staff)

Has the applicant has ever signed off from a vessel on Medical Grounds. If yes, please furnish details.
Yes No
Name of Vessel Date signed off Reason / Brief Description of Illness / Injury / Accident

Have you visited the doctor in the last 12 months for any surgery / Illness. If yes, please furnish details
Yes No
Date of Illness / Surgery Details of Illness and Treatment received

Please answer the below, by ticking the appropriate box.

Were you ever denied a foreign visa. If yes, please furnish details. Yes No
Are you willing to sail one rank lower ? Yes No
Does the applicant have any history of accidents during his seaservice ? Yes No
If yes, please give details on a separate sheet of paper.
Has the applicant been convicted in a court of Law (Civil / Criminal) ? Yes No
Are any legal proceedings pending against you ?
If yes, please give details on a separate sheet of paper.

Have you had any serious injuries , sicknesses, operations in the last one year, Yes No
If Yes please give details in separate sheet.

References

Name of Person Company / Address (No Relatives) Contact numbers & Email Id

I, hereby declare that all the details given in this application are true. Further, I understand that the company can
hold me liable and refuse any claim for treatment, cost of any other Insured benefits if a complete and
true statement of all previous Illnesses is not given.

Signature of Applicant Date and place

FOR OFFICE USE

All documents checked/verified with originals. Candidates general health & appearance & spoken english is satisfactory.

Name and Signature of Interviewer / Date and place

Manning Representative

Form FP-01 / rev. 1 / 09-2013

Practical Experience : Have you experience of the following (Please signify thus 'X')
New Building Planned Maintenance System
Steam Turbines Carg (a) Computerised (Specify)
Engine Driven Cargo Planned Maintenance System
Cargo Pump type (a) Computerised (Specify)
a) Centrifugal pumps (b) Others
b) Screw pumps Container (specify TEU)
c) FRAMO Pump Reefer container
Cargo Reefer plant Reefer Cargo
Deck crane type Dry dock
a) Thyrister control Major repairs
b) Electrical Major Fire
c) Electro hydraulic Collision
d) Gantry Pollution Incident
Knowledge of ships electrical and
Crude Oil Washing Operations electronic system
Knowledge of vessels automation
Inert Gas Systems and computerized system

Enumerate the different Nationalities you have sailed :

Officers :
Ratings :

Reason for application : State why you wish to leave your present employment:-

Preference for employment on : Tanker or Dry Cargo

May we approach your PRESENT employer for Reference Name :

May we approach your PAST employer for Reference ? Te Name :
Have you ever had to leave a Company other than volunta
What date are you available for sea service ?

1. Stability software experience ?

2. Ship maintenance software experience?
3. Cargo crane experience?
4. ECDIS experience?
5. Stevedore damages experience?
6. Reefer containers experience ?
7. Dry dock experience during last three years ?
8. Shipyard delivery team experience ?
9. UMS vessels, last three years?
10. Hazardous cargo carriage in last three years ?
11. Types of Cargo Cranes previously worked with:

Dry Docks
Yard Delivery
Audits / Inspections/Vetting/PSC etc.

Kindly let us know where did you find out about our recruitment
* Newspapers * Friends

* Internet * Others (Please specify)

Declaration
I certify that the details given by me in filling up this form are true, complete, and correct to the best of my knowledge and belief. I understand that
misrepresentation or material ommision made in this application form or other documents submitted to Trinitas Ship Management may renders me liabl
termination or dismissal.

Date: Signature of the Applicant: Place:

Form # 07-5/2 (Issue 1 Rev.0)

Maintenance System
terised (Specify)
Maintenance System
terised (Specify)

(specify TEU)

e of ships electrical and

e of vessels automation
uterized system
my knowledge and belief. I understand that any
tas Ship Management may renders me liable for