OFFSHORE STAFF APPLICATION FORM

Application for Offshore Employment

POSITION APPLIED FOR: Select Position_

(This form is to be filled by the applicant in BLOCK LETTERS. Attach all attested photocopies of all certificates of competency and
proficiency and all other documents that support this application.)

THIS FORM HAS BEEN DESIGNED TO PROVIDE US WITH THE BASIC INFORMATION REQUIRED FOR FACILITATING THE PROCESSING OF YOUR
APPLICATION FOR YOUR EMPLOYMENT WITH US. IT ALSO SERVES AS PERSONAL RECORD SHOULD YOU BE EMPLOYED. IT IS THEREFORE ESSENTIAL FOR
YOU AND HELPFUL FOR THE APPRAISAL THAT THE FORM IS COMPLETED NEATLY AND FACTUALLY. ALL PARTS ARE TO BE COMPLETED. DELETE ITEMS
WHICH ARE NOT APPLICABLE TO YOU.

PERSONAL PARTICULARS
Name as per NRIC/Passport
NRIC (for Malaysian only)      
Nationality      
Date of Birth      
Place of Birth      
Marital Status      
Religion      
Home Address      

Contact Number Main:       Alternative:      

Email Address      
Nearest Airport       Insert Picture
PPE Size Coverall: Select Safety Boots: Select
Bank / Account No.      
EPF No.       NEXT OF KIN’S
Socso No.
PARTICULAR
(IMPORTANT)
Name as per NRIC/Passport
Relationship      
Date of Birth      
Home Address      

Contact Number Main:       Alternative:      

Email Address      

IDENTIFICATION AND TRAVEL DOCUMENT DETAILS

Passport No.      
Date of Issue      
Date of Expiration      
Issuing Country      

SEA GOING DOCUMENTS

Seaman Card No.       Seaman’s Book No.      
Date of Issue       Date of Issue      
Date of Expiration       Date of Expiration      
Issuing Authority       Issuing Authority      

C.O.C/Watch keeping Cert/ Cert      

of Qualification as
Chef/Cook/Steward
Date of Issue      
Date of Expiration      
 OFFSHORE STAFF APPLICATION FORM
Issuing Authority      

Place Medical Examination      

Date of Issue      
Date of Expiration      
Vaccination Yellow Fewer: Cholera: Others:      

EDUCATION BACKGROUND
College/School Attended Period Qualification Obtained
                 
                 
                 
                 

TRAINING AND OTHER CERTIFICATES

Certificates Date of Issue Place/College of Issue
Basic Safety Training (BST) / BOSET            
Personal Survival Techniques            
Basic Fire Fighting            
Elementary First Aid            
Personal Safety and Social Responsibility            
Proficiency in Survival Craft and Rescue Boat            
Fast Rescue Boat            
Advance Fire Fighting            
Medical First Aid            
Medical Care            
ARPA operation Cert            
Radar Simulator            
Radar Observer            
General Operator Certificate (GMDSS Operator)            
Electronic Navigation Aid            
Tanker Familiarization            
Ship Security Officer Certificate            
Shipboard Management Certificate            
Bridge Team Management            
Dynamic Positioning Induction Course            
Dynamic Positioning Simulator Course            
Dynamic Positioning Operators Certificate            
Other Certification            
****PLEASE ATTACH A COPY OF ALL THE DOCUMENTS AND CERTIFICATES*****

TOTAL DP HOUR AND DP EXPERIENCE

System Details Total Hours obtained (hrs) Type of Operation
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
           

SEA GOING EXPERIENCE

Vessel Name Company Type of Vessel DWT or Type of BHP Rank Sign on Sign off
 OFFSHORE STAFF APPLICATION FORM
GRT Engines Date Date
Or DP
System
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     

REFEREES (Two referees who are not member of immediate family)

Name Position Company Contact Number
                       
                       
                       
                       

MEDICAL HISTORY
 OFFSHORE STAFF APPLICATION FORM
(It is of utmost importance that all illness other than minor afflictions 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 illness has not been
given)
(A) Have you ever signed off a ship due to medical reasons? Yes No
(If yes, please provide following details:)
Date of Place of
Name of Vessel                  
Occurrence Occurrence
Brief Description of illness / injury / accident:
     

(B) Have you undergone any medical operation in the past? Yes No
Details of Operation Date Period of Disability Present Condition
                       
                       
                       
(C) For what illness or accidents have you consulted a doctor during the last 12 months?
Details of illness Date Therapy / Treatment
                 
                 
                 
(D) Please give details of any health or disability problem.
Details of illness Date of occurrence
           
           
           

1. ADDITIONAL INFORMATION
i) Have you ever been denied a foreign visa? If yes, please state country and reason (if known): Yes No
ii) Willing to accept lower rank? Yes No
iii) Ability writing in English? Yes No
iv) Ability speaking and understanding in English? Yes No
v) Have you been the subject of a court enquiry or involved in a maritime accident? If yes, please attach
Yes No
details.
vi) Have you ever work for Company or Vessel which are having ISM / ISO Certifications? If yes, please
Yes No
indicate details below.
Company Vessel Position Date Sign On Date Sign Off

                             

                             

                             

Are you bound by any contract or agreement to serve any statutory body or organization?
Yes / No
 OFFSHORE STAFF APPLICATION FORM
Declaration

I here by certify that the information contained in this application is to the best of my knowledge correct, and that I have withheld
nothing what so ever that would affect this application. I also understand that falsification or misrepresentation (intentionally or
unintentionally) in this or any other personnel records can result in my immediate dismissal and forfeiture of all wages, allowances and
benefits if I am employed by the Company

I also agree to undergo strict medical examination and drug & alcohol test as a pre-requisite before appointment and I confirm my
willingness to provide the consulting physician with full details of my accurate medical history.

Signature of Applicant:       Date:      

Name:      

Reserved For Official Use Only

     
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Selected / Not Selected For Employment

Vessel:      
Rank:      
Salary:      
Date of Engagement:      
Name of Appraiser:      
Signature of Appraiser:      

APPROVED
REJECTED
KIV