MD-CSE-001 (03/21) Page 1 of 3

GRAND SEAS SHIPPING, CORP.

EMPLO
DATE OF APPLICATION May 03, 2021 REFERRED BY Recent
Photo FORM
POSITION APPLIED FOR OILER VESSEL TYPE General Cargo

FIRST NAME: KENNETH PAUL MIDDLE NAME BAGON LAST NAME LAZARRA

Directions: Write legibly. Do not leave any item unanswered. Put N/A on items that are not applicable.
PERSONAL INFORMATION

CITY ADDRESS ORAS, EASTERN SAMAR LANDLINE/MOBILE

NO.09271301617
PROVINCIAL ADDRESS EASTERN SAMAR LANDLINE/MOBILE NO.

SEX M AGE 27 DATE OF BIRTH PLACE OF BIRTH: DA’O NATIONALITY FILIPINO RELIGION CATHOLIC
07/18/93 ORAS, EASTERN
SAMAR
CIVIL STATUS Single TIN: N/A SSS No. 34-5759822-7 PHILHEALTH NO. PAG-IBIG NO.
080260828723 916070363989
HT. 5’6 WT. 62 BOILER SUIT SIZE: SHOE SIZE: DRIVER’S LICENSE

NEXT-OF-KIN: ZOLITA LAZARRA, B. RELATIONSHIP LANDLINE/MOBILE NO. 09263632284

MOTHER
ADDRESS DA’O ORAS, EASTERN SAMARA

EDUCATIONAL BACKGROUND

LEVEL SCHOOL/EDUCATIONAL INSTITUTION YEARS INCLUSIVE DEGREE/HONORS/ AWARDS

FROM TO EARNED
HIGH Name MERCEDES NATIONAL HIGH 2006 2010 N/A
SCHOOL SCHOOL
Address
MERCEDES, EASTERN SAMAR
VOCATIONAL Name
SCHOOL N/A
Address

COLLEGE Name EASTERN VISAYAS STATE 2010 2014 N/A

UNIVERSITY
Address
TACLOBAN CITY

CERTIFICATES OF COMPETENCY

ISSUING AUTHORITY RANK LICENSE NO. DATE OF ISSUE DATE OF EXPIRY

NATIONAL (D-COC) OILER 157374 04/16/2019 04/14/2024
NATIONAL (COC/COE) N/A
NAVIGATIONAL WATCH N/A
MARINA SID N/A

OTHER CERTIFICATES / DOCUMENTS

TYPE CERTIFICATE DATE OF ISSUE DATE OF EXPIRY

NO.
SEAMAN’S BOOK (SIRB) A0042391 08/12/2020 08/12/2030
REGISTRATION CERTIFICATE (SRC)
YELLOW FEVER EXPIRES ON:

COURSES CERTIFICATE NO. DATE OF ISSUE DATE OF EXPIRY

Advance Training for Chemical (ATOC) with COP

Distribution – Marine Department

 MD-CSE-001 (03/21) Page 2 of 3
Advanced Training in Fire Fighting (ATFF) with COP
Advanced Training for Oil Tanker Cargo Operations (ATOT) with
COP
Advanced Training for Chemical Tanker Cargo Operations
(ATCT) with COP
Advance Training for Liquefied Gas Tanker Cargo Operations
(ATLGT)
Automatic Radar Plotting Aid (ARPA)
Basic Training (BT) with COP BT200033358220 12/28/2020 12/28/2025
COURSES CERTIFICATE NO. DATE OF ISSUE DATE OF EXPIRY
Basic Training (BT) Refresher
Basic Training For Oil and Chemical Tanker Cargo Operation BTOC200007761220 12/28/2020 Unlimited
(BTOCT) with COP
Bridge Teamwork Management (BTM)/ Bridge Resource
Management (BRM)
Electronic Chart Display and Electronic System – ECDIS (as
applicable)
Global Maritime Distress & Safety System (GMDSS)
INMARSAT (as applicable)
MARPOL 73/78 Annex I-VI (CONSOLIDATED) BC9-2020-01342 11/09/2020 Unlimited
Medical Emergency First Aid (MEFA) with COP
Medical Care ( MECA ) with COP
Passenger Ship Crowd Management Training
Passenger Ship Crisis Management and Human Behavior
Training
Proficiency on Survival Craft &Rescue Boat (PSCRB) BC8-2020-02441 11/2/202 Under process of marina
Radar Observation and Plotting (ROP)
Radar Simulator Course (RSC)
Ship Security Awareness Training & Seafarers with Designated SDSD200006065420 12/28/2020 Unlimited
Security Duties (SDSD) with COP
Ship Security Officer Course (SSO) with COP
Shipboard Safety Officer (SBS)
Ship Restricted Radio Telephone Operator’s Course (SRROC)

Others: (please specify)

STCW 2010 CERTIFIC

SEA EXPERIENCE

Start with your most recent employment.

Distribution – Marine Department

 MD-CSE-001 (03/21) Page 3 of 3
VESSEL TYPE/ FLAG GRT ENGINE PRINCIPAL/ RANK SIGN ON SIGN OFF REASON
STATE MAKE/BHP MANNING
AGENCY
General
Cargo
499
JB&Son Oiler For
Salvacion-8
Philippines 735.27 shipping 08/30/201 07/31/2020 drydock
Corp. 9 shipyard
LCT 709 Good will For
Blue Philippines 496.06 Lighterage Engine 08/04/201 04/06/2019 drydock
Drago Corp. Cadet 8 shipyard
n

MEDICAL HISTORY
It is important that all illnesses (minor and major) should be stated. The Company is entitled to refuse any claim for treatment, cost or any
other insured benefits if a complete statement of all previous illnesses has not been given.
(A) Please give details of any present/ past health problems:

* This may include self-assessment of your present medical conditions ((like showing signs of COVID19 symptoms (e.g. fever, dry
cough, colds, headache, diarrhea, body aches/fatigue): (specify symptoms) (B) Please give details of any medical benefits claimed:

APPLICANT’S SIGNATURE : INTERVIEWER’S SIGNATURE:

Kenneth Paul B Lazarra DATE: ____________ DATE: ____________

___05/03/2021_________ With my signature, I hereby attest and Position
certify that all information as stated above are true and correct, and
that any false statement or undisclosed material and/or information
with regards to my past or present employment and medical history
will disqualify me from any employment, benefits and/or claims.

That, I further hold myself liable for perjury, falsehood,

misrepresentation or omission or any act of dishonesty for any
fraudulent, false, and tampered documents that I have submitted and
hereby indemnify the company against any claims or demands
whatsoever which may at any time be made against the company, or
any of them by reason of any fault, defect, omission, or inaccuracy in
the content of the Certificates or other documents.

That, I am fully aware that any misrepresentation is a ground for

prosecution / administrative penalties or sanctions.

That I attest to the truthfulness of this undertaking and I submit to the

legal and administrative consequence thereof if the statements above
are wanting in truth and substance.

Distribution – Marine Department