Online Application

Position

* Position applied for:
* Are you willing to accept any other positions? If YES, which positions would you consider?	Yes	No
Are you responding to a media advertisement? If YES, please state which publication	Yes	No
From what date will you be available?
Publication name:

PERSONAL INFORMATION

* Name
Date/Place of Birth:				Nationality:
Permanent Address
					* Pin Code:
	* E-Mail:		* Tel No. :		Mobile
Local address:
					Pin Code:
	E-Mail:		Tel No. :		Mobile

Identity documents

DOCUMENT	COUNTRY	NUMBER		DATE OF ISSUE				PLACE OF ISSUE				DATE OF EXPIRY
Passport:	MYANMAR
Seaman Book:	National
	Panamanian
	Liberian
	Others
Do you hold a US Visa 'C1/D'?		Yes	No	Issue Date:						Expiry Date:
Do you hold a US Visa 'B1/B2'?		Yes	No	Issue Date:						Expiry Date:
Have you been rejected for any visa applied for?				Yes No
If YES, please state the country and reasons

Family Details: (If Unmarried kindly give details of Father / Mother)

NAME	Relation	DOB	POB	PASSPORT NO.	PLACE OF ISSUE	DATE OF ISSUE	DATE OF EXPIRY	ECNR

Certificates (Highest certificate of competency held)

Grade/Class Of COC Country	Issuing Country	Date of Passing Exam	Certificate No.	Date Issued	Place Issued	Valid Until

Certificates Of Competency issued by other countries

(Issued by countries other than in Section 6)

Issuing Country	Certificate No.	Date Issued	Place Issued	Valid Until
Panama
Others

Record of previous service

(Please give a full record starting with the last vessel on which you served)

COMPANY	VESSEL NAME	VESSEL TYPE	D.W.T/GRT	CONTS TEU’S	VSL AGE	TYPE OF ENGINES (Please give full dtls)	B.H.P	RANK	SIGN ON mm/dd/yyyy	SIGN OFF mm/dd/yyyy	DURATION mm/dd/yyyy	REASONS FOR S/OFF

Medical history

Have you ever signed off a ship due to medical reasons?	YES  NO
Have you undergone any operation in the past?	YES  NO
Have you consulted a doctor during the last 12 months for an illness/accident?	YES  NO
Do you have any health or disability problems now?	YES  NO
(If the answer is YES to any of the above, please give full details and attach a separate page if necessary)

General

Have you ever been the subject of a court of enquiry or involved in a maritime accident?	YES  NO
Have you ever had a professional license suspended or revoked?	YES  NO
(If YES, please give full details and attach a separate page if necessary)

References

Name of company
Name of person to contact
Address
☎ No.

(Please give the name and address of your current or immediate past employer)

Review

If immediate employment is not available, do you wish to be considered for future vacancies?	YES  NO
If YES, please give any alternative contact details not shown in Section 2

Declaration

I hereby declare that the above particulars are true and authorise you to contact the referees listed above.
Date:

BOILER SUIT SIZE:

SAFETY SHOE SIZE:

Height:

Weight:

BMI: