Eastern Pacific Shipping Pte Ltd.

EMPLOYMENT APPLICATION FORM

RECENT PASSPORT SIZE

COLOUR PHOTOGRAPH
STAFF CODE: RANK:
Office use only

VESSEL:
DATE AVAILABLE:
Office use only

SURNAME: FIRST NAME: OTHER NAME:

DATE OF BIRTH: PLACE OF BIRTH: NATIONALITY:

PASSPORT NO. ISSUED ON: EXPIRY DATE:

S/BOOK NO. ISSUED ON: EXPIRY DATE:

PERMANENT
ADDRESS:

PHONES: FAX: E-MAIL:

NEXT OF KIN: NAME:

Relationship

ADDRESS:

PHONES: FAX: E-MAIL:

NEAREST For officers - Please specify the nearest domestic

AIRPORT: airport. For all ratings - the nearest international airport.

MARITAL STATUS: SPOUSE NAME:

MARRIAGE DATE:

CHILDREN

SON / DAUGHTER NAME DATE OF BIRTH

PRE-SEA TRAINING / MARITIME SCHOOL / HIGHEST ACADEMIC QUALIFICATION (Specify School Name / Country, and Year attended)

Course Name Institude Name From Date - To Date

PAGE 1 OF 7 OFC06-05/19
 Eastern Pacific Shipping Pte Ltd.

DOCUMENT STATUS

LICENSES GRADE REGULATION NUMBER ISSUE EXPIRY PLACE Authenticated

NATIONAL LICENSE (LIC) (Please refer to Note below)

NATIONAL DANGEROUS CARGO ENDORSEMENT (DCE) - OIL

NATIONAL DANGEROUS CARGO ENDORSEMENT (DCE) - CHEM

NATIONAL DANGEROUS CARGO ENDORSEMENT (DCE) - GAS

REVALIDATION OF NATIONAL LICENSE (REV)

S T C W COURSES Mark / Delete GRADE REGULATION NUMBER ISSUE EXPIRY PLACE Authenticated
SURVIVAL AT SEA / PERSONAL SURV. TECH. (SAS / PSST)

FIRE PREV. AND FIGHTING

ELEMENTARY FIRST AID / MEDICAL FIRST AID / MEDICAL CARE

PERSONAL SAFETY AND SOCIAL RESPONSIBILITIES (PSSR)

TANKER FAMILIARIZATION COURSE - OIL

TANKER FAMILIARIZATION COURSE - CHEM

TANKER FAMILIARIZATION COURSE - LPG

ADVANCED TANKER COURSE - OIL

ADVANCED TANKER COURSE - CHEM

ADVANCED TANKER COURSE - LPG

PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOAT (PSCRB)

ADVANCED FIRE FIGHTING

MEDICAL FIRST AID AND MEDICAL CARE

GMDSS

BRIDGE TEAM AND RESOURCE MANAGEMENT (BTRM)

ENGINE TEAM RESOURCE MANAGEMENT (ETRM) / ERM

ELECTRONIC CHART DISPLAY AND INFORMATION SYSTEM (ECDIS)

as per IMO 1.27

RISK MANAGEMENT AND INCIDENT INVESTIGATION COURSE (RMI)

SAFETY OFFICER COURSE (SOT)

SHIP SECURITY OFFICER (SSO)

SDSD-Designated Security Duties = YES

HIGH VOLTAGE TRAINING COURSE (C/E, 1/AE, 2/AE, 3/AE, E/E)

ENVIRONMENTAL OFFICER TRAINING COURSE

RADAR OBSERVER (ROC)

ARPA / RADAR SIMULATOR

OTHER COURSES GRADE REGULATION NUMBER ISSUE EXPIRY PLACE

SHIP HANDLING SIMULATOR & BRIDGE TEAM (SHS)

LIQUID CARGO HANDLING SIMULATOR (LCH)

ISM

ENGINE SIMULATOR COURSE

U.S. VISA C1/D STATUS

YELLOW FEVER

LIBERIAN SEAMAN'S BOOK

LIBERIAN LICENSE

LIBERIAN GMDSS CERTIFICATE

LIBERIAN "TANKERMAN (OIL / CHEMICAL / LPG)

LIBERIAN SPECIAL QUALIFICATION CERTIFICATES

SINGAPORE CERTIFICATE OF ENDORSEMENT (COE)

SINGAPORE - TANKER ENDORESEMENT (MGMT / OPERATIONAL)

SINGAPORE GMDSS CERTIFICATE OF ENDORSEMENT (COE)

Note: For Deck Officer, the COC should be valid for Navigational Watch on ships 500 gross tonnage or more.

PAGE 2 OF 7 OFC06-05/19
 Eastern Pacific Shipping Pte. Ltd.

DETAILS OF PREVIOUS SEA SERVICE

LAST VESSEL ON TOP

PERIOD OF SERVICE
Vessel Details
(For Engine Staff : Vessel Type / Engine
YEAR details : Example : Container Carrier / DWT NAME OF OWNERS / MANAGERS
NAME OF VESSEL
BUILT
FLAG
B&W - 12K98MC-C) H.P.*
RANK
AND THEIR CONTACT DETAILS Period in Months
FROM TO
(For Deck Officers : Vessel Type / ECDIS. (DD/MM/YYYY) (DD/MM/YYYY)
Example: Container, JRC 201C)

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0
1. APPLICANTS TO ENSURE THAT COMPLETE SEA SERVICE FROM THE BEGINNING OF SEA CARRIER IS GIVEN. IF THIS PAGE IS INSUFFICIENT, PLEASE MAKE A PHOTOCOPY OF THIS PAGE AND WRITE THE SEA SERVICE.
2. ENGINE DEPARTMENT APPLICANTS ESPECIALLY ENGINEERS TO ENSURE THAT HORSE POWER & DEAD WEIGHT IS WRITTEN UNDER COLUMN (TYPE OF VESSEL/MAN ENGINE DETAILS).
3. MANNING OFFICE TO VERIFY AND ENSURE THE ABOVE SEA-SERVICE IS TALLYING AGAINST CANDIDATE'S NATIONAL SEAMAN BOOK.
4. CANDIDATES APPLYING FOR LPG FLEET PLEASE SPECIFY WHICH SHIPS WERE FULLY PRESURIZED, SEMI-REFRIGERATED AND FULLY REFRIGERATED UNDER COLUMN (TYPE OF VESSEL/MAN ENGINE DETAILS).
5. PLEASE DO NOT CHANGE THE PAGE LAYOUT AND MARGINS.
Example : BSN, A/B x 3, O/S x 2, PMN 7
Manning Info of last vessel : Please specify ranks and number onboard Count
Deck Officers : MST, C/O, 2/O, 3/O
Deck Ratings : BSN, A/B, O/S, PMN
Engineers : C/E, 1A/E, 2A/E, 3A/E,E/E,G/E) Was last vessel running in UMS ?
Engine Ratings : OLR, WPR, FTR) _______
Catering : (Cook, STW, MSB/CBY)
Cadets : (DCT, ECD. ELC)
Total 0

PAGE 3 OF 7 OFC06-05/19
 Eastern Pacific Shipping Pte Ltd.

SUMMARY OF OFFICER'S EXPERIENCE In years and months

Crude Oil Product Chemical LPG
EXPERIENCE AS Bulk Geared Bulk Container Car Carrier TOTAL
Tanker Tanker Tanker Tanker

MASTER C/E

C/O 1/AE

2/O 2/AE

3/O 3/AE

G/E E/E

TOTAL

ENGINE APPLICANT DECK APPLICANT

TYPE OF AUXILIARIES Please mention MODEL & TYPE TYPE OF ECDIS Please mention MODEL & TYPE

GENERATORS JRC

BOILERS FURUNO

PURIFIERS TRANSAS

COMPRESSOR PAPERLESS NAVIGATION EXPERIENCE:

ELECTRONIC MAIN ENGINE EXPERIENCE:

EXPERIENCE WITH MULTINATIONAL CREW: YES / NO NATIONALITY: YEARS / MONTHS:

REASON FOR LEAVING LAST COMPANY: YES / NO IS APPLICANT 18 YEARS OR ABOVE? YES / NO

AGREEABLE TO ACCEPT ONE RANK LOWER : YES / NO AGREEABLE TO JOIN VSL PLYING IN WAR ZONE HIGH RISK AREA: YES / NO

Blood Type: Height Safety Shoes

Eye Sight with Glasses: Weight Boiler Suits

Eye Sight without Glasses: BMI Parka

APPLICANT'S DECLARATION: (Answers to questions A, B, C & D has to be either 'Yes' or 'No')

A. HAVE YOU BEEN THE SUBJECT OF A COURT OF ENQUIRY OR INVOLVED IN A MARITIME ACCIDENT? _________
B. I CONFIRM THAT I AM WILLING TO WORK ONBOARD EPS VESSELS WITH ZERO ALCOHOL POLICY. ______

MEDICAL HISTORY:
ALL PREVIOUS ILLNESSES OTHER THAN MINOR ILLNESSES SHOULD BE STATED BELOW OR UPDATED. IF NOT PREVIOUSLY DISCLOSED, THE COMPANY IS
ENTITLED TO REFUSE ANY REIMBURSEMENT OF MEIDCAL COSTS, CLAIM FOR TREATMENT OR FOR ANY OTHER INSURED BENEFITS.
C. HAVE YOU EVER SIGNED OFF A SHIP DUE TO MEDICAL REASONS? ______
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

D. HAVE YOU UNDERGONE ANY OPERATION IN THE PAST? ______ IF YES, PLEASE PROVIDE FOLLOWING DETAILS :
DETAILS OF OPERATION DATE PERIOD OF DISABILITY PRESENT CONDITION

E. FOR WHAT ILLNESSES OR ACCIDENTS HAVE YOU CONSULTED A DOCTOR DURING THE LAST 12 MONTHS?
DETAILS OF ILLNESS / ACCIDENT DATE THERAPY / TREATMENT

F. PLEASE GIVE DETAILS OF ANY HEALTH, ALLERGY OR DISABILITY PROBLEM

DETAILS:

I hereby confirm that all my certificates [Certificate of Competency, STCW certificates and other qualifications] are genuine and authentic. I confirm that I am NOT holding any fake
certificates.

I declare that all information provided herein is to the best of my knowledge is true and correct. I am fully aware that witholding or providing wrong information will lead to
termination of employment and commencement of criminal proceedings.
I have read and understood the Recruitment Privacy Notice.

Signature Date of application

I have confirmed the applicant is holding the certificates require as per QSP0912/0913 applicable for his position.

EPS Representative / Agent Date

PAGE 4 OF 7 OFC06-05/19
 Eastern Pacific Shipping Pte Ltd.

EVALUATIONS
(For All Ranks)

Date :
Manning office :
Applicant’s name :
Rank :
Biodata Number :

Reference Check - 1 (Last Employer)

Employer’s Name and contact details

Reference check date :

Name of Person Giving this reference:
Detailed references (To be listed point by point)
1
2
3
4
5
6
7
8 Name of person taking reference
9
10

Reference Check - 2 (Previous Last Employer)

Employer’s Name and contact details

Reference check date :

Name of Person Giving this reference:
Detailed references (To be listed point by point)
1
2
3
4
5
6
7
8 Name of person taking reference
9
10

Special Remarks / Comments

Recommendation from any Ex EPS staff or Reliable known persons.

PAGE 5 OF 7 OFC06- 05/19

 Eastern Pacific Shipping Pte Ltd.

CARGO INFORMATION SHEET

NOTE: Tick appropriate box for cargoes carried, and comment in the space provided.

Fleet A – GAS TANKERS Fleet A – PRODUCT / CRUDE TANKERS

Acetaldehyde JET A1
Anhydrous Ammonia NAPTHA
Butadiene PREMIUM UNLEADED PETROL (UNDYED)
Butane PREMIUM UNLEADED PETROL (DYED)
Butane / Propane Mixture UNLEADED PETROL / MOGAS
Butene LEADED PETROL / MOGAS
Butylenes AUTOMOTIVE GAS OIL
Diethyl Ether VGO
Dimethylamine CAT CRACKED GASOLINE
Ethyl Chloride CRACKER FEED
Ethane LIGHT CYCLE OIL
Ethylene Oxide / Propylene Oxide Mixtures REFORMATE
Isoprene FUEL OIL 380 CST
Isopropylamine FUEL OIL BLEND COMPONENT
Methyl Acetylene – Propadiene Mixture HIGH SULPHUR FUEL OIL
Methyl Chloride LOW SULFUR WAXY RESIDUE
Monoethylamine CUTBACK BITUMEN
Propane BITUMEN FEEDSTOCK
Propylene CRUDE OIL
Vinyl Chloride Monomer CONDENSATE
Vinyl Ethyl Ether HIGH POUR POINT CRUDE
Vinylidene Chloride CLOUD POUR POINT CRUDE
Crude C4 CRUDE WITH HIGH VAPOUR PRESSURE
Methane HEATED CARGO
Fully Pressurized Ships
Semi Pressurized / Refrigerated Ships
Fully Refrigerated Ships
Special Cleaning After Prop OX (Give Details)
Special Cleaning After Butadiene (Give Details)
LPG

Fleet A – CHEMICAL TANKERS

Aromatics: Chemical Products :
Benzene Caustic Soda
Epichlorohydrin (ECH) Chloroform
Molasses MDI / Diphenylmethane Diisocyanate/ TDI
Xylene Ethylene Dichloride (EDC) / Methylene Dichloride
Alcohols & Glykols Styrene Monomer
Styrene MethylTert-Butyl Ether (MTBE)
Toluene Butyl Acetate
Methanol Acetone
Ethanol Acrylonitrile
IPA - Iso-propyl Alcohol / NBA Vinyl Acetate Monomer (VAM)
Butyl/Isobutyl Alcohol Urea Ammonia Nitrate
2-Ethylhexanol (Octanol) Dowanol
Mono Ethylene Glycol (MEG) Dodecylbenzene (Lab)
Acids : Perchlorethylene
Sulfuric Acid Trichlorethylene
Nitric Acid Phenol
Acrylic Methyl Ethylene Glycol (MEG)
Acetic Lub Additives / Lubrizol
Phosphoric Acid Sodium Hydrosulphide
Hydrogen Peroxide Propylene Oxide / Ethylene Oxide
Paraffins :
Paraffin Wax Wall Wash Testing (HC / CL)
Slack Wax Passivating Stainless Steel Tanks
Cyclohexane Permangemate Testing (PTT)
Hexane N2 Padding
Veg Oils:
Crude Palm Oil, Rapeseed Oil, Soyabean Oil, Sunflower Oil
PAGE 6 OF 7 OFC06-05/19
 Eastern Pacific Shipping Pte Ltd.

CARGO INFORMATION SHEET

NOTE: Tick appropriate box for cargoes carried, and comment in the space provided.

Fleet B – BULK CARRIERS Fleet C - (CONTAINER AND CAR CARRIER)

Alumia Ore DG Cargo

Sugar Iron Reefer containers

Lime / Cement Sand & gravel Mediterranean Mooring

Understanding of the Regulation regarding Verification
Petcoke Copper
of the Gross Mass (VGM) of a packed Container
Grain Limestone

Salt Silica Sands

Steel Products Pig Iron

Bagged Cargo Timber (UnderDeck)

Coals Machinery (Boxed)

Experience on geared bulk carrier / bulk carrier with cranes

(please advise numbers and types of the cranes)

OTHER INFORMATION / AREAS OF KNOWLEDGE

Oil Company Inspections / CDI (Please List)

Trade Areas (Please list in details last 2-3 vessels' trading areas)

Deep Well Pumps Experience (Types of Pumps)

Centrifugal Pumps Experience

Specialized Framo Pumps / Cargo System

Working experience on Oil Tanker with Pumproom

Closed Loading / VECS.

Cargo Heating – Oil / Steam / Deck htr (Please List)

Tank Coating Type – Zn / SS / EPOXY (Please List)

Cargo Cooling Systems

Compressor Types

Inert Gas

Gas Freeing

Specialist Gas Training

Experience of changeover of grade (Please give details about
cargo grade changed over)

Bunker Management Procedure (Experience of changeover of bunker

for SECA & ECA (Please give details on which vessel)

STS (Ship-To-Ship) experience

Lightering Experience - Please list in detail

Transshipper Experience - Please list in detail

Dry Dock Experience (Indicate shipyard and vessel name)

New Delivery Experience from Shipyard (Indicate shipyard, vessel name)

Trading Area (Indicate areas)

Ice Navigation Experience (Indicate areas)

Scrubber experience (List vessel name where Scrubber was operational)

Type of Ballast Water Treatment Plant

SCR - Selective Catalytic Reduction

Parcel Trade Experience

Competencies for Fitters, Pumpman & Engine Ratings

Brazing skills (especially on refrigeration lines) Ability to perform Gas Welding

Welding skills – including gouging, grinding Ability to perform Grinding / drilling

Pipe fabrication including T-joints and Flange joints TIG Welding proficiency

Ability to carry inter-tank repairs & stainless steel repairs Ability to Repair & overhaul Machineries

Operational knowledge of engine overhaul & pump overhaul Other Skills - please mention in details

Gas cutting experience Plumbing Skills

Carpentery Skills

PAGE 7 OF 7 OFC06-05/19