Northpoint Corporate Tower

7502 Bagtikan cor. Guijo Sts. San Antonio Village, 1203 Makati City
Tel. no. / Fax No.: +632 856-5338
Email: [email protected] * [email protected] * [email protected]
Website: www.seacrestmaritime.com

APPLICATION/CREW DATA FORM

Date of Application: 04/20/21

Position Applied For: Chief Mate

Alternative Position: Chief Mate

*PLEASE ENSURE THAT ALL REQUIRED INFORMATION ARE FILLED OUT.

A. PERSONAL INFORMATION
Surname: Somoza First Name: Graham Middle Name: Cesar

Date of Birth: Oct 29, 1972 Place of Birth: Balingoan, Mis. Age: 48 Sex: X
Or. Male Female

Blood Height (cm): Weight (kg): Eye color: Religion:

Type:A/B 179 94 Black Roman Catholic
Permanent Address: Zip Code: 6014
L.C. Cabrera St., Gethsemane rd., Casuntingan, Mandaue City, Cebu,
Telephone No.: 09288035640 Mobile No.: 09174067113 E-mail Address: [email protected]

Contact Address: L.C Cabrera st., Gethsemane rd., Casuntingan, Mandaue City, Cebu Tel. No.:
09174067113
SSS No.: 3329442951 PhilHealth No.:120252537951 PAG-IBIG TIN: 2001874117
No.:121109690741
Civil Spouse’s Name: (Last name, Given name, Middle Spouse’s Maiden Name: (Last name, Given name, Middle Name)
Status:Married Name) Tacandong, Hazelle Caiña
Somoza, Hazelle Tacandong
Date Married: No. of Children: 3 Place of Birth: Date of Birth:
Sep 27, 2003 Talisayan Mis. Or. Jun 03, 1972

Tel./Mobile No.: 09174067113 Occupation: N/A PhilHealth No.:

Father’s Name: (Last name, Given name, Middle Name) Date of Birth: Occupation: Tel. No.:
Somoza, Isidoro Balingit
Address:

Mother’s Name:(Last name, Given name, Middle Mother’s Maiden Name:(Last name, Given name, Middle Date of Birth:
Name) Name)
Somoza, Bernadette Cesar Cesar, Bernadette Mercado
Address: Occupation: Tel. No.:

CHILDREN
Child1: Place & Date of Birth: Child3: Place & Date of Birth:
Antonio Miguel T. Somoza Cebu, Sep 16, 2004 Andres Miguel T. Somoza Cebu, Apr 07, 2013

Child2: Place & Date of Birth Child4: Place & Date of Birth:
Jose Miguel T. Somoza Cebu, Oct 24, 2005

Namet of Kin:Hazelle T. Somoza Date of Birth: Jun 03, 1972 Relationship: Wife

Address of Kin: L.C Cabrera st., Gethsemane rd., Casuntingan, Mandaue City, Cebu Tel. No.: 09174067113

Allotee 1: Hazelle T. Relationship: Wife Date of Birth: Jun 03, 1972 Place of Birth: Talisayan, Mis.
Somoza Or.

Address:L.C Cabrera st., Gethsemane rd., Casuntingan, Mandaue City, Cebu Contact No.:

CREWING 002 Rev. No.: 09 Date Issued: 23-MAR-2017 Page 1 of 6

 Allotee 2: Relationship: Date of Birth: Place of Birth:

Address: Contact No.:

B. EDUCATION
Highest Educational Attainment: BSMT Attendance Date: 1991-94

Name of School/Institute: University of Cebu

Numbe
C. DOCUMENTS r
Date Issued Expiry Date Place of Issue
P624129
1. Philippine issued Passport 7B
08 Feb 2021 07 Feb 2031 Cebu
C12935
2. MARINA Seaman’s Book No. (SIRB) 16 Jun 2018 13 Jun 2024 Cebu
46
026405
3. Seaman’s Registration Certificate (SRC) 27 Apr 2016 Nil Cebu
6
4. PRC License
GOC20
5. GMDSS License 000125 26 Nov 2019 26 Nov 2024 Cebu
7519
6. NBI Clearance
CMM20
7. Certificate of Competency (COC) 000022 05 Sep 2019 05 Sep 2024 Cebu
8919
EMM20
8. Certificate of Endorsement (COE) 000022 05 Sep 2019 05 Sep 2024 Cebu
6119
GOC20
9. GOC for GMDSS Endorsement 000125 26 Nov 2019 26 Nov 2024 Cebu
7519
10. NC I - Ship’s Catering Services for Messman
11. NC III - Ship’s Catering Services for Cook
12. Others
D. VISAS
200931
1. US Visa C1D: 301400 08 Nov 2004 08 Nov 2014 Manila
01
2. US Visa B1/OCS:
3. Australian Visa:
4. Schengen Visa:
5. Norwegian Visa:
E. FLAG STATE ENDORSEMENT
1. Antigua & Barbuda License
2. Bahamas License
3. Cyprus License
4. Danish License/ DRC
5. Hongkong License
98154
6. Liberia License 29 Oct 2020 Manila
4
7. Malta License
60864
8. Marshall Island License 028 Oct 202 Manila
3
9. MPA License
10. Panama License 5 Sep 2024 Manila
11. St. Vincent and the Grenadines License
12. St. Kitts and Nevis License
13. Others (please specify)
F. HEALTH, SAFETY AND SECURITY TRAINING
CERTIFICATES
BT20002
14. Basic Training (BT) 9547320
15 Oct 2020 15 Oct 2025 Cebu
15. Basic Training – Updating
16. Refresher Training for Basic Training 34667 22 Sep 2020 Cebu
17. Updating PSSR Training
AFF200
18. Advanced Training in Fire Fighting (ATFF) 0085749 15 Oct 2020 15 Oct 2025 Cebu
20

CREWING 002 Rev. No.: 09 Date Issued: 23-MAR-2017 Page 2 of 6

 182171
19. Medical Emergency First Aid (MEFA) 28 Oct 2015 Nil Cebu
26
196796
20. Medical Care (MECA) 13 Feb 2016 Nil Manila
7
21. Ship Security Training and Seafarers with Designated
Security Duties (SDSD)
222875
22. Ship Security Officer (SSO) 05 Feb 2014 Nil Manila
4
23. Ship Security Awareness (SSA)
G. TANKER TRAINING CERTIFICATES
BTOC20
24. Basic Training for Oil and Chemical Tanker Cargo Operations
0004442 26 Nov 2019 26 Nov 2024 Cebu
(BTOC) 819
25. Basic Training for Liquefied Gas Tanker Cargo Operations
(BTLGT)
ATOT20
26. Advanced Training for Oil Tanker Cargo Operations (ATOC) 0000549 26 Nov 2019 26 Nov 2024 Cebu
019
ATCT20
27. Advanced Training for Chemical Tanker Cargo Operations
0000372 26 Nov 2019 26 Nov 2024 Cebu
(ATCT) 719
28. Advanced Training for Liquefied Gas Tanker Cargo
Operations (ATLGT)
H. DECK TRAINING CERTIFICATES
29. Operational Use of Electronic Chart Display System (ECDIS) 01704 14 Oct 2016 Nil Cebu
2019016
30. ECDIS – Type Specific : FURUNO 17
06 Mar 2019 Nil
31. Management Level for Deck Officers (MLC DECK) 01882 19 Dec 2015 Cebu
32. Updating Management Level Course
33. Operational Level Course for OIC - Deck
34. Radar Observer Course (ROC) 00688 11 Oct 1997 Nil Cebu
DU1020
35. Automatic Radar Plotting Aids (ARPA) 091232
7 May 2009 Nil Tacloban
DU1020 Tacloban
36. Radar Simulator Course (RSC) 091232
7 May 2009 Nil
37. SRROC
38. INMARSAT
39. IMDG/ HAZMAT
40. GOC FOR GMDSS 00106 17 Apr 2009 Nil Cebu
41. Bridge Resource Management (BRM) 12769 24 Jan 2014 Nil Manila
BTM092 29 Nov
42. Bridge Team Management (BTM) 3645
Nil Manila
2016
43. Ratings Forming Part of Navigational Watch (RFPNW)
39. OTHERS
I. ENGINE TRAINING CERTIFICATES
40. Management Level for Engine Officers (MLC ENGINE)
41. Updating Management Level Course
42. Operational Level Course for OIC - Engine
43. Engine Room Simulator Course (ERSC)
44. Engine Room Resource Management (ERRM)
45. Auxiliary Machinery
46. Control Engineering
47. Hydraulics & Pneumatics
48. Ratings Forming Part of Engineering Watch (RFPEW)
J. CATERING TRAINING CERTIFICATES
49. Culinary & Catering Course
50. Catering Management
51. Messman Course
52. Food Handling
53. Food Hygiene
K. OTHER CERTIFICATES
04013020
54. Consolidated MARPOL 73/78 Annex I-VI 13 12 Apr 2013 Nil Cebu
55. ISM Code Familiarization
56. ISPS Familiarization
57. Dangerous, Hazardous and Harmful Cargoes 061101 30 Nov 2016 Nil Manila
OTSC874
58. Inert Gas System / Crude Oil Washing 95 02 Dec 1995 Nil Manila
59. Maritime Law
60. Prevention of Alcohol and Drugs in the Maritime Sectors
61. OTHERS (please specify)
L. OFFSHORE TRAINING CERTIFICATES
CREWING 002 Rev. No.: 09 Date Issued: 23-MAR-2017 Page 3 of 6
 62. Smoke Diving Course
63. Basic Offshore Safety Induction and Emergency Training
64. Tropical Basic Offshore Safety Induction and Induction and
Emergency Training
65. Tropical Further Offshore Emergency Training
66. Further Offshore Emergency Training
67. Helicopter Underwater Escape Training
68. OTHERS (please specify)
M. VACCINATION
Yellow Fever:QJ 035010 Validity: Lifetime
Others: Validity:

CREWING 002 Rev. No.: 09 Date Issued: 23-MAR-2017 Page 4 of 6

 N. Sea Experience: most recent experience on the top
Type Engine Made Flag Signed on Signed off Total
Name of Vessel Rank Manning Agency Remarks
Gross Tonnage Horsepower Year Built (dd/mm/yy) (dd/mm/yy) Months
1. MT New Sena C/M Oil Chem Panama Interworld ship 25 Dec 20 3 Jul 20 6 F/C
7745 2010

2. MT Armonia C/M Oil Chem Marshall Island Admiman 14 Jan 19 20 Jun 19 6 F/C
9366 2011
3. MT Peninsula VIII C/M Oil Chem Isle of Man Admiman 28 Mar 18 28 Jul 18 4 F/C
8455 2007

4. MT Palenque ! C/M Product Tanker Panama Michaelmar 9 Jan 17 17 Jun 17 6 F/C

24733 1992
5. MT Levanto C/M Oil Chem Liberia PTC 26 Jun 16 30 Sep 16 4 F/C
11118 2002
6. MT Levanto Tr.C/M Oil Chem Liberia PTC 22 May 16 25 Jun 16 6 Promoted
11118 2002
7. MT Captain Gregory 2/M Product Tanker Liberia PTC 11 May 15 23 Oct 15 6 F/C
23386 1998
8. MT Levanto 2/M Oil Chem Liberia PTC 7 May 14 11 Jan 15 8 F/C
11118 2002
9. MT Araevo 2/M Oil Chem Liberia Bright maritime 26 May 13 28 Nov 13 1 F/C
18625 1991
10. MT Araevo 3/M Oil Chem Liberia Bright maritime 22 Apr 13 25 May 13 1 Promoted
22943 1980
11. MT Aetos 2/M Oil Chem Liberia Status maritime 31 Dec 11 8 May 12 4 F/C
22943 1980
12. MT Aetos 3/M Oil Chem Liberia Status maritime 14 Sep 11 30 Dec 11 3 Promoted
22943 1980
13.MT Greataf 3/M Oil Tanker Liberia PTC 30 Oct 10 8 Apr 11 6 F/C
80274 1988
14. MT Bora 1 3/M Product Tanker Tanzania Bright maritime 31 Jan 10 5 Sep 10 7 F/C
15215 1975
O. Uniforms Size I hereby testify that all information given by me are correct and true

CREWING 002 Rev. No.: 09 Date Issued: 23-MAR-2017 Page 5 of 6

 Cover-All XXL and that all submitted documents are genuine and obtained legally;
and hereby undertake to abide faithfully to the Code of Discipline as per POEA Rules and Regulations (Rule VI).
Safety Shoes 9.5

White Polo XXL Graham C. Somoza

__________________________________ __________________________________
Black Pants (Waist Line) 36 Signature of Applicant Assessor

CREWING 002 Rev. No.: 09 Date Issued: 23-MAR-2017 Page 6 of 6