002060BSM MARINE LLP01+000
Form: PER 1
Seafarer's Application Form
Application for the Post of :
Date of Application :
Photograph
Date of Availability :
Licence as: Issuing Authority:
Marital Status: Single Married Divorced Widower Seperated Sex: Male Female
Surname: First Name: Middle Name:
Nationality: Date of Birth: Place of Birth:
Height:(CMS) Weight:(KGS) BMI: Shoe size:
Boiler Suit Size: Hair Colour: Eye Colour: Identity Mark:
Permanent Address: Temporary Address:
Pin Code: Pin Code:
Tel. No. Tel. No.
Mobile No. Mobile No.
E.Mail: E.Mail:
International Airport: Dstic Airport:
Dist. to Nearest Airport : Kms Time to nearest Airport:
Hrs.
Travel Documents:
Documents Number Place of Issue Date of Issue Nationality Expiry Date
Passport
Seaman Book
Seaman Book
U.S. Visa
Other Documents:
Yellow Fever
INDoS
Dated : 1st. March'2022
Version No.01 CONTROLLED DOCUMENT Page 1 of 4
Revision No.:00 Frequency : During Crew Selection File : Office
002060BSM MARINE LLP01+000
Form: PER 1
Seafarer's Application Form
Licenses:
Cert. Name Grade Number Date of Issue Nationality Expiry Date
COC(National)
CEC(Flag Endorse)1
CEC(Flag Endorse)2
GMDSS
GMDSS Endorsement
Watchkeeping Cert.
Dangerous Cargo Endorsements:
Level(Sup/ Number Place Of Issue Issue Date Nationality Expiry Date
Document Ops/Mgmt)
Oil
Chemical
Gas
Next of Kin Details
Name Relationship Percentage DOB Address Contact No.
Father
Mother
Educational Qualifications(Highest Qualification to be entered):
Name of the School / College Qualification From To
Pre-Sea Training:
Name of the School / College Qualification From To
Courses:
Cert. Name Number Name Of Institute D.O.Issue Place Of Issue D.O.Expiry
FPFF
Dated : 1st. March'2022
Version No.01 CONTROLLED DOCUMENT Page 2 of 4
Revision No.:00 Frequency : During Crew Selection File : Office
002060BSM MARINE LLP01+000
Form: PER 1
Seafarer's Application Form
Cert. Name Number Name Of Institute D.O.Issue Place Of Issue D.O.Expiry
AFF
PSSR
Elem First Aid
Medical First Aid
Medicare
PST
PSC
STSDSD
Ship Security Offcr
Oil Tkr Fam.
TASCO
CTFC
CHEMCO
GTFC
GASCO
Bridge Team Mgmnt
Bridge Resource Mgmt
ROC
ARPA
RANSCO/NARAST
Ecdis(5days,1.27)
Ship Manoevr Simu.
Engine Room Simu.
Ship Safety Offcr.
Lq Cgo Hand. Simu.
Pumpman Training
Cookery Course
ITI Course
Dated : 1st. March'2022
Version No.01 CONTROLLED DOCUMENT Page 3 of 4
Revision No.:00 Frequency : During Crew Selection File : Office
002060BSM MARINE LLP01+000
Form: PER 1
Seafarer's Application Form
Cert. Name Number Name Of Institute D.O.Issue Place Of Issue D.O.Expiry
Marine Pollution
6gwlding(Class Aprvd)
Reval and Updating
Medical History:
Have you signed off on Medical Grounds from any Vessel ? Yes No
If Yes give details
Have you undergone any major / minor surgery ? Yes No
If Yes give details
Do you suffer from any of these ?
Heart Trouble Yes No
High / Low Blood Pressure Yes No
Epilepsy Yes No
Temporary Blindness / Blurring of Vision Yes No
Any other ailment which would affect your working Yes No
If Yes give details
Have you been refused visa by any country ? Yes No
If Yes give details
Have you been deported from any country ? Yes No
If Yes give details
References:
Name Designation Name Of the compny Contact details
Dated : 1st. March'2022
Version No.01 CONTROLLED DOCUMENT Page 4 of 4
Revision No.:00 Frequency : During Crew Selection File : Office
002060BSM MARINE LLP Form: PER 1
Sea Service Details : Mention Details of Last Vessel Served on TOP(Please use addtional sheets if required)
Company Vessel Name Flag Type GRT DWT BHP Engine Make / Type Rank From To Duration Reason for sign off
I warrant and represent that:
1. The foregoing details are true, accurate and complete. I hereby authorise company to authenticate my previous service records as deemed necessary.
2. There are no contractual or other restrictions (other than official visa/ work. Permit Approvals) or health conditions that may in any way Prevent or restrict me
from being employed by you and fully performing my work.
3. I apply for employment with you by my own free will without any inducement or representative from you or your agents.
4. Further that no Certificate of competency or license issued to me has ever been revoked or suspended.
5. I also certify that my medical history contained above is true and any false statement or undisclosed Material information about past illness or injury will
disqualify me from any employment benefits and claims.
6. I hereby authorise company and give my concent to share my medical report details with the Master and any other persons as deemed necessary.
Date: Sign of Seafarer: Name:
Version No.-01 Dated : 1st. March'2022 Page 5 of 2
Revision No.:00 CONTROLLED DOCUMENT File: Office
Frequency : During Crew Selection
002060BSM MARINE LLP Form: PER 1
FOR OFFICE USE ONLY:
Evaluation:
Name: Rank:
First assessor:
Name: Designation: Sign:
Mode of assessment:(Pls Tick) Physical Presence: Video Conference: Telephonic: Date:
Approval Status:(Pls Tick) Approved: To Be Reinterviwed: Not Approved:
Remarks:
Second assessor:
Name: Designation: Sign:
Mode of assessment:(Pls Tick) Physical Presence: Video Conference: Telephonic: Date:
Approval Status:(Pls Tick) Approved: To Be Reinterviwed: Not Approved:
Remarks:
Below acknowledgement to be given to the seafarer:
Acknowledgement Slip
Received Application From Rank: On:
Received By: Sign:
Version No.-01 Dated : 1st. March'2022 Page 6 of 2
Revision No.:00 CONTROLLED DOCUMENT File: Office
Frequency : During Crew Selection
