COMPANY OPERATING MANUAL

APPENDIX COMPANY FORMS

Form Number
: CRW/13

Document Number
Revision Number
Page Number

:
:
:

VMS/COM/01
04
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Application
[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]

Individuals Code Number

1. Personal Data
First Name

Middle Name (s)

Last Name / Surname

Nationality (or current

Citizenship )

Country of Origin

Date of Birth:
/ /

AFFIX YOUR
RECENT
PASSPORT SIZE
PHOTOGRAPH
HERE

Place / City of Birth

(DD / MM / YY)

Marital Status1:

Religion:
Male

Female
1
Select from : Single Married Divorced Common Law Partner Widowed Separated
Gender :

Rank applied for:

Willing to accept lower rank? Yes

No

Available From (date): / /

(DD / MM / YY)

Primary / Permanent Address:

Alternative / Temporary Address:

Until: / /

City:

Post Code:

City:

Post Code:

State:

Country :

State:

Country:

Nearest Airport :

Home Tel:

Phone:

Mobile Tel.

Fax:

Email:

Contact Method :
Collar: cm

Email

Fax

Chest: cm

Specify size as S, M, L, XL, XXL for :

2.

Mobile Phone

Waist: cm
Sweater size:

Home Phone

Inside Leg:

cm

Boilersuit size:

Cap:

Post
cm

Personal ID / Documents / Visa

Type of Document / ID 1

Country of Issue

No.

Date of Issue
(DD / MM / YY)

Issued at (Place)

Valid Until
(DD / MM / YY)

Seamans Book (National)

/ /

/ /

Passport

/ /

/ /

US Visa C1/D

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO

Social Security
Number:

Issuing Country

Personal Tax
Number:

Issuing Country:

COMPANY OPERATING MANUAL

APPENDIX COMPANY FORMS
Form Number
: CRW/13

Document Number
Revision Number
Page Number

:
:
:

VMS/COM/01
04
2 of 6

3. Nominee / Next of Kin & Family Details

Full Name of Nominee for compensation in case of fatality:

Relationship1

Gender : Male

Nationality :

Female

Address:

City:

Post Code:

Country:

Email:

Tel:

Mobile:

Select From : Spouse Partner Child Parent Grand Parent Other Relative (Please Specify)

Family Data:
Relationship
Spouse / Partner2
Child

Child

Child

Child

Child

F
F
F

First Name

Last Name

Date of Birth

Passport No.

Issued

Place

Valid Until

Indicate type of valid visa

2

Strike out inapplicable item

USA
3

Canada

Brazil

Schengen

UK

Other

Please consider period on board

4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: (Add separate sheet if data exceeds space available.)
Description of Cert /
Course

Country of
Issue

Number

(A)
Reg I
Personal Training Record Reg I/14

Medical Fitness Cert Reg I/9

(B)
Reg VI / 1 Basic Safety Training
Personal Survival Techniques

Elementary First Aid

Fire Fighting & Fire Prevention

Personal Safety & Social Resp.

(C)
Reg VI / 2 4 Additional Training
Proficiency in Survival Craft & Rescue Boat

Fast Rescue Boats

Advanced Fire Fighting

Medical First Aid

Medical Care (Master / C/O)

Date of
Issue
(DD-MMYY)

Date of
Expiry
(DD-MMYY)

Place of
Issue

Issuing Authority /
Body

/ /
/ /

/ /
/ /

/ /
/ /
/ /
/ /

/ /
/ /
/ /
/ /

/ /
/ /
/ /
/ /
/ /

/ /
/ /
/ /
/ /
/ /

Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag
state endorsements)
4
/ /
/ /

/ /
/ /

/ /
/ /

(D)

/ /
/ /

/ /
/ /

Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you

(E)
Other mandatory/recommended Certificates / Courses (as applicable)

ARPA (Reg II/1 + Solas)

/ /
/ /

Radar Simulator

English Language

Bridge Team / Resource Mgmnt

Hazmat (US 49CFR)

Shiphandling/ShipManoeuvring
Simulator
Shipboard Security Officer

/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /

/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /

Select as applicable: Passport Seamans Book Seaman Passport Seafarers Identity Document Registration Book National ID Card PAG-IBIG
Housing Insurance Health Insurance Overseas Emp Cert PHL Card Pension Fund Provident Trust Professional Organisation Driving Licence Visa
Vaccination Yellow Fever.

COMPANY OPERATING MANUAL

APPENDIX COMPANY FORMS
Form Number
: CRW/13

Document Number
Revision Number
Page Number

/ /
/ /
/ /
/ /
/ /

/ /
/ /
/ /
/ /
/ /

:
:
:

VMS/COM/01
04
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COMPANY OPERATING MANUAL

APPENDIX COMPANY FORMS
Form Number
: CRW/13

Description of Cert /
Course

Document Number
Revision Number
Page Number

Country of
Issue

Date of
Issue
(DD-MMYY)

Number

(F)
GMDSS Certificates (including flag state endorsements)

GMDSS (Main Issuing Authority)

GMDSS (Flag State)

GMDSS (Flag State)

GMDSS (Flag State)

GMDSS (Flag State)

GMDSS (Flag State)

/ /
/ /
/ /
/ /
/ /
/ /

Reg V / 1 Special Requirement for Tankers

Level1:
Country
Description
Incharge
of Issue
Level2: Asst.
Endorsement Oil

:
:
:

Date of
Expiry
(DD-MMYY)

/ /
/ /
/ /
/ /
/ /
/ /

VMS/COM/01
04
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Place of
Issue

Issuing Authority /
Body

(G)

(H)

Date of
Issue
(DD-MM/ /

Endorsement Chemical

/ /

Endorsement Gas

/ /

/ /

Number

Place of
Issue

Issuing Authority /
Body

Tanker Familiarisation

(Oil)

Para 1

Tanker Familiarisation

(Chemical)

Para 1

/ /

Tanker Familiarisation

(Gas)

Para 1

/ /

Special Tanker Safety

(Oil)

Para 2

/ /

Special Tanker Safety

(Chemical)

Para 2

/ /

Special Tanker Safety

(Gas)

Para 2

/ /

V/2 and V/3 Special requirement for Passenger / Ro-Ro Passenger Vessels
Vsl Type
Date of
Country of
Place of
Description
Number
-Pax /
Issue
Issue
Issue
RoRoPax
(DD-MM

Crowd Management

/
/
Crisis Mgmnt & Human Behaviour

Pax Safety, Cargo Safety & Hull Integrity

Pax Safety

Familiarisation Training

Safety Training

/ /
/ /
/ /
/ /
/ /

Issuing Authority /
Body

5. Sea Experience : (Last 5 years; Start the listing below with the most recent experience)

Date
Date To
From
dd/mm/yy
dd/mm/yy

Company

(1)

Flag & Vessel Name

Type

(1)

GRT

DWT

Main Engine

(2)

BHP

Rank

Use only the following abbreviations for vsl types:

B/C
CON
CHM
CH3
DRG
DP
FSH

Bulk Carrier
Cellular Container
Chem Carrier IMO I-II
Chem Carrier IMO III
Dredgers
Dynamic Positioning
Fishing Vsl

FPSO
GCD
HLV
LSH
LIV
LNG
LOG

FloatgProdStorOffldg
General Cargo
Heavy Lift Vsl
Lash
Live Stock Carrier
LNG Carrier
Log/Timber

MLP
MSV
NVL
RIG
OSV
OBO
O/O

Multi-purpose
MultiServiceVessel
Naval Ship
OffShore Oil Rig
OffShore Supply Vsl
Ore/Bulk/OilCarrier
Ore/OilCarrier

PAS
RFG
R/R
PRR
SAL
SRV
SUL

Passenger Ship
Reefer Vessel
Ro/Ro Carrier
RoRo-Pax
Sailing Vsl
Survey Vessel
Self-Unloader

YAT
TNB
TNC
TNP
TNS
TNV

Yacht
Tanker(Bitumen)
Tanker(Crude)
Tanker(Products)
Tanker(Storage)
Tanker(VLCC/ULCC)

COMPANY OPERATING MANUAL

APPENDIX COMPANY FORMS
Form Number
: CRW/13

FSO
(2)

FloatingStorageOffldg

LPG

Document Number
Revision Number
Page Number

LPG Carrier

OTH

Engineers to give make/model of engines, e.g. MAN 14V52/55A or SULZER 5RTA58

Other

TUG

Tug

:
:
:

VMS/COM/01
04
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COMPANY OPERATING MANUAL

APPENDIX COMPANY FORMS
Form Number
: CRW/13

Document Number
Revision Number
Page Number

:
:
:

VMS/COM/01
04
6 of 6

6. Medical History:
Sheet 4
All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed, the
Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured
benefits.
(A)

Blood Type

Have you ever signed off a ship due to medical reasons?

Yes
No
If yes, please provide following details (If space is insufficient, attach additional sheets) :

Name of vessel

Date of occurrence

Place of occurrence

Brief description of illness/injury/accident

(B) Have you undergone any operation in the past?

If yes, please provide following details:

Yes

No

Details of operation

Date

Period of disability

Present condition

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
Details of illness / accident

Date

Therapy/Treatment

(D) Please give details of any health or disability problem

Details:

7.

Bank Details:

Other Details: (if any)

Bank Name
Address

Account Name
Account No.
Sort Code

8.

General

(A)

Have you ever been denied a foreign visa?

Yes
No
If yes, state which country and reason (if known)
(B) Have you been the subject of a court of enquiry or involved in a maritime accident?
If yes, please attach details
(C) Give details below of two recent employers who we may contact for references:

Yes

Name of Company
Name of person to contact
Address

Reference 1

Reference 2

Country
Telephone

No

I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by you and any of your direct or indirect parent or subsidiary or
associated or affiliated companies (V Ships) and your or V Ships principals of personal data about me (including where appropriate data concerning racial or ethnic origin, religious
beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and the outcome of any proceedings
relating thereto) for all purposes related to my application for employment on board vessels managed by V Ships or vessels owned or operated by third parties for whom V Ships is
engaged to provide crew. I understand that this data will be stored in your databases in relation to my actual or potential employment by or through V Ships. Further, I confirm that the
above may involve the transfer of my personal data within V Ships or to third parties worldwide.

Place:
For Office Use:

Date:

Signature:.