APPLICATION FORM

Form Ref. No.: MANSHIP QP07-04

PLEASE WRITE ALL DATES AS YYYY/MM/DD.

Date of Application: __ _ __ _ _ _ __ _ _ _ _
Position Applied For: _______________
Please select

Alternative Position: ________________

Please select

Seafarer Code: _____________________

How did you learn about MANSHIP?
 Referral (Please specify relationship) ___________________________________
 Online (Website Name/Address) ______________________________________
 Seafarer Center
Preferred Vessel Type: Date of Availability:
PERSONAL DATA
Last Name: First Name: Middle Name:
Nickname: Age: Birthdate: Birthplace:
Religion: E-mail:
Telephone No.: Mobile No.:
SSS No.: PhilHealth No.:
TIN: Pag-IBIG No.:
Permanent Address: House No./Unit No. with Floor and Building, Street/Lot and Block Nos., Barangay, Subdivision (as applicable)

Municipality/City ZIP Code Province

Current Address: House No./Unit No. with Floor and Building, Street/Lot and Block Nos., Barangay, Subdivision (as applicable)

Municipality/City ZIP Code Province

Civil Status: Spouse’s Full Birth Name: Last Name First Name Middle Name
Please select
Date of Marriage: Spouse’s Birthdate: Spouse’s Contact No.:
Spouse Works? Yes No No. of Children: No. of Dependents (PhilHealth):
` `
Father’s Full Birth Name: Last Name First Name Middle Name

Mother’s Full Birth Name: Last Name First Name Middle Name

EDUCATIONAL INFORMATION
Name of College: From To
Course: Vocational Nautical Degree Other Degree
` ` `
High School:
Spoken English: Very Good Good Satisfactory Native Dialect:
` ` `
EMERGENCY CONTACT DETAILS
Person to Contact in Case of Emergency:
Contact No.: Relationship:
Address: House No./Unit No. with Floor and Building, Street/Lot and Block Nos., Barangay, Subdivision (as applicable)

Municipality/City ZIP Code Province

BACKGROUND INFORMATION
A. Have you ever been denied an application for any visa or entry into another country? Yes No
If your answer is yes, please explain below.

B. Have you ever been detained or ordered to leave any country? Yes No
If your answer is yes, please explain below.
C.

D. Have you ever been subjected to any disciplinary action during an employment contract? Yes No
If your answer is yes, please explain below.
E.
SEA SERVICE (Please provide a clear copy of your sea service records.)
Year Engine Manning Principal/ Date Joined Date Left Month/ Cause of
Vessel Name Vessel Type Flag GRT HP/KW (YYYY/MM/DD) (YYYY/MM/DD) Rank
Built Type Agency Shipowner Days Discharge
 MEDICAL BACKGROUND INFORMATION
F. Have you been clinically diagnosed with any medical condition? Yes No
If yes, kindly state the medical conditions below.

G. Have you been assessed a disability grading? Yes No

If yes, please describe the assessment and state whether the grading assessed is partial or full.
H.
Have you ever been prescribed maintenance medication? If yes, please state below. Yes No

NATIONAL CERTIFICATES AND TRAVEL DOCUMENTS

Passport No.: Issued: Expiry: Place Issued:
SIRB No.: Issued: Expiry: Place Issued:
COC No.: Issued: Expiry: Rank:
COE No.: Issued: Expiry: Rank:
Date of First Issuance of COC at currently held rank:
SRC/ERN: Issued: Rank:
US Visa (C1/D) Yes No Place Issued: Expiry:
Schengen Visa (Type C) Yes No Place Issued: Expiry:
Yellow Fever No.: Place Issued: Date Issued:
TRAINING AND OTHER CERTIFICATES
Please check the box if you possess any of the specified certificates
 COP – AFF  COP – MECA  ACNI  INMARSAT
 AFF  MECA  ARPA/ROPA  ISM
 COP – ATCT  COP – MEFA  BRM/BTM  MARITIME ENGLISH
 ATCT  MEFA  COW/IGS  MARPOL I-VI
 COP – ATOT  COP - PFRB  CULINARY/MESSMAN COURSE  MLC – Deck/Engine
 ATOT  PFRB  DWK/EWK  OLC – Deck/Engine
 COP – BT  COP - PSCRB  ECDIS GENERIC  RSC
 BT  PSCRB  ECDIS SPECIFIC: ____________________  SBFF
 COP – BTOC  COP – SSA/SDSD  ERS/ERM  SHIP HANDLING
 BTOC  SSA/SDSD  FRAMO  SHIP VETTING
 COP – GMDSS/GOC  COP – SSO  GTF  SOC
 GMDSS/GOC  SSO  HAZMAT  SSBT
Others (Please specify brand): Flag Documents:
1.  Cayman Islands  Liberia  Netherlands
2.  Cyprus  Malta  Singapore
3.  Isle of Man  Marshall Islands  Others:________
ESSAY
Kindly say something about yourself and your qualifications. Tell us why we should hire you.

CERTIFICATION
1. I certify that all information I have provided in this Application Form is true and correct to the best of my knowledge.
2. I agree that if I have withheld or misrepresented any information in this Application Form, I alone am responsible and
accountable for any consequence of such withholding or misrepresentation.
3. I understand that the information I provided in this Application Form shall remain confidential but I may be held liable
for any untruthful statements made therein.
Printed Name: Signature: Date:
 DATA PRIVACY NOTICE AND PERSONAL DATA PROTECTION CONSENT FORM

MANILA SHIPMANAGEMENT & MANNING, INC. (“MANSHIP”) shall protect the data that you provided in
compliance with the Data Privacy Act of 2012 (the “DPA”) and its implementing rules and regulations. MANSHIP
shall not collect, disclose, or process personal data, including data that may be classified by law as personal
information or sensitive personal information (all hereinafter referred to as the “DATA”), unless you voluntarily
choose to provide MANSHIP with the DATA and consent to MANSHIP’s collection, disclosure, or processing
thereof, or unless such disclosure is required by applicable laws, rules, and regulations. Personal or sensitive
personal information refers to information pertaining to racial or ethnic origin, religious beliefs, political
affiliations, education, health, or information provided by government agencies which are unique to individuals,
and such other data declared by law to be sensitive.

By signing above your name on the space indicated below, you confirm that you freely and voluntarily consent
to MANSHIP’s collection of DATA set out in this form or otherwise provided by you or possessed by MANSHIP
for any or all of the purposes stated below:

(a) collection and processing of your employment application and/or preparation of your contract;
(b) administering and/or managing your engagement, relationship, or association with MANSHIP or any of
its principals;

MANSHIP shall keep the DATA for a period of ten (10) years. MANSHIP shall take appropriate and commercially
reasonable technical and organizational measures to ensure data security to protect the DATA against
unauthorized disclosure or unauthorized access. MANSHIP shall require its personnel, affiliates, subsidiaries, and
third parties who process the DATA to adhere to similar or comparable data protection standards as required
by the DPA.

You understand that you are given certain rights under the DPA which includes the right to object to the
processing of your data, the right to access your data, the right to correct any inaccurate data, and the right to
erasure or blocking of data. For more information on these rights or for the submission of requests to review
the DATA, to withdraw your consent to the use of the DATA for any of the purposes stated above, or to correct
or update the DATA, please contact our Data Protection Officer, Atty. Jason Roland P. Gacayan, at
legal@manship.com.

__________________________
Signature above printed name

__________________________
Date
DO NOT FILL BELOW THIS LINE
REFERENCE 1
Verified By: Date:
Company Name: Person Contacted:
Veracity of Seagoing History: Health Problem:
Financial Liability: Comments:
Character:

REFERENCE 2
Verified By: Date:
Company Name: Person Contacted:
Veracity of Seagoing History: Health Problem:
Financial Liability: Comments:
Character:

Revision 11
20190204

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