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

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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

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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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