BSM Application Form

Pass Fail
Recruitment
Initials
Ops. Dept. Intro to Principal
PERSONAL DATA/APPLICATION FORM

S
BSM Crew Service Centre Philippines, Inc.
Rank/Position Applied For: Deck Cadet
Last Name: First Name Middle Name

Garces Tee Jay Hernandez
Home Address: San Antonio San Pascual Batangas Tel. No.
Contact Address: San Antonio San Pascual Batangas Cell No. 09568044208
Email add: [email protected]
Place of Birth: Pasig City Civil Status: Single
Wedding Date:
Course Finished: Bachelor in Marine
Year
Transportation
Attended Name of School: Lyceum International Maritime Academy
From:(dd/mm/yy) To: (dd/mm/yy)
2018 2021
Interests/Activities/Hobbies: Hard working person, Cycling, Cooking
For Office Staff Use Only:

 IHTS Height: Cm
Languages Spoken (pls. check all applicable choices): Blood Pressure: Weight: Kg
 English
 Filipino Religion: _ BMI:
Others
SSS No.: TIN No.: PAG-IBIG No.: PHILHEALTH No.:
Cholera Exp.: Yellow Fever Reference No.: Year Started Seagoing Years in Present Employment:
Employment:
Next of Kin
Name: Marcelino Hernandez Date of Birth (dd/mm/yyyy): Relationship: cousin
October 25, 1985
Address: San Antonio San Pascual Batangas Telephone No.:09395450677
Children Below 21 Years Old

Name Sex Date of Birth (dd/mm/yy)
Total No. of Children:

Parents Details
Mother’s Maiden Name: Father’s Name:
Maria Hernandez Teodoro Garces
Date of Birth: January 3 Date of Birth:
1981 August 28,
Home Address: OFW
BSM/Ser 11/Effective 19.06.18/PDAF

SEA-GOING EXPERIENCE
(most recent vessel first)
Previous Salary:
Salary Expectation:
Foreign Principal & Signed on Signed off No. of Type of DWT & Nat. of Nat. of
Local Agency Rank Vessel's Name & Flag Trade Route M.E. Make BHP or KW Cause of Discharge
Address (dd/mm/yy) (dd/mm/yy) Months Vessel GRT Master/Offs Ratings
BSM/Ser 08/Effective 21.01.13/PDAF 2 of 5

CERTIFICATION AND OTHER DOCUMENTS
LICENSES AND DOCUMENTS
DATE ISSUED EXPIRY DATE LEVEL NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
CERTIFICATE OF COMPETENCY (OFFICERS)
CERTIFICATE OF ENDORSEMENT (OFFICERS)
CERTIFICATE OF PROFICIENCY (NWK / EWK)
CERTIFICATE OF PROFICIENCY (ABLE SEAFARER)
BOARD LICENSE
NC I - NC III
28/07/21 28/07/31 A0011271
SEAMAN'S BOOK 14/10/19 13/10/29 P3512338B
PASSPORT
U.S. VISA
POEA E-Registration (ERN)
GOC
NATIONAL CERTIFICATIONS
DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
BASIC SAFETY COURSE
COP BT 28/0721 28/07/26 BT200045231421
ADVANCE SAFETY COURSE
CoP Advanced Training in Fire Fighting
CoP Proficiency in Survival Craft & Rescue Boat
CoP Medical Emergency - First Aid
CoP Medical Care
CoP Proficiency in Fast Rescue Boat
TANKER TRAINING CERTIFICATES
CoP Basic Training Oil/Chemical Tanker
CoP Basic Training Liquefied Gas Tanker
CoP Advanced Training in Oil Tanker
CoP Advanced Training in Chemical Tanker
CoP Advanced Training in Liquified Gas Tanker
NAVIGATIONAL
CoP Ship Security Officer
CoP SDSD / SAT 28/07/21 Unlimited SDSD200007497221
Safety Officer Course
ECDIS (Generic)
ECDIS (Specific)
CERTIFICATION AND OTHER DOCUMENTS
FLAG DOCUMENTS & CERTIFICATES
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
SEAMAN'S BOOK
OTHER CERTIFICATES:
1
2
3
SEAMAN'S BOOK
OTHER CERTIFICATES:
1
2
3
SEAMAN'S BOOK
OTHER CERTIFICATES:
1
2
3
SEAMAN'S BOOK
OTHER CERTIFICATES:
1
2
3
S
BSM Crew Service Centre Philippines, Inc.
WORKING EXPERIENCE (pls. check all applicable)
 WATER TUBE BOILERS  HEAVY LIFT OPERATORS
 DUAL EVAPORATION BOILERS  COMPUTERS
 THERMAL OIL BOILERS  HYDRAULIC POWER PACKS
 MEDIUM SPEED ENGINES  SATELLITE TELEX
 SLOW SPEED ENGINES  RADIOTELEX
 ELECTRIC WELDING  ETHYLENE OPERATIONS
 GAS WELDING  DECK CRANES
 ELECTRONICS  OBO OPERATION
 AUTOMATION  INERT GAS SYSTEMS
 FRAMO PUMPS  REEFER CONTAINERS
 SUBMERSIBLE PUMPS  DERRICKS
 CRUDE OIL WASHING  TURBO GENERATORS
 BOW THRUSTER
Shore Employment Details

DATE
FROM TO Nature Of Employment Employers Name and Address
Working Gear Size

Collar (Cm): Chest (Cm): Waist (Cm):
Shoes (Cm): Winter Jacket: Rain Coat:
DECLARATION
I certify that the above information is true and accurate. No Certificate of Competence or License issued to me
has ever been revoked or suspended. Any false information would lead to denial of application.
I agree that during this application process I will be subjected to a computer based Professional and English
Language assessment test. The results of which is form part of this application.
I hereby confirm that I had no jail term and not admitted to a mental institution prior employment via BSM Crew
Service Centre Philippines, Inc.
I hereby confirm that I was never repatriated on medical grounds nor ever involved in an accident on board nor
ever required medical treatment following contract completion.
I hereby confirm that I had no past history of any serious medical condition which will affect my work ability at
sea.
I hereby confirm that I had not taken any disability compensation from any employer in the past due to a
condition which permanently affect my ability to work at sea.
9/17/2021
Signature Date

BSM Application Form

Uploaded by

Copyright:

Available Formats

BSM Application Form

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

BSM Application Form

Uploaded by

Copyright:

Available Formats

Pass Fail

PERSONAL DATA/APPLICATION FORM

Last Name: First Name Middle Name

Place of Birth: Pasig City Civil Status: Single

For Office Staff Use Only:

SSS No.: TIN No.: PAG-IBIG No.: PHILHEALTH No.:

Children Below 21 Years Old

Total No. of Children:

BSM/Ser 11/Effective 19.06.18/PDAF

BSM/Ser 08/Effective 21.01.13/PDAF 2 of 5

Shore Employment Details

Working Gear Size

Shoes (Cm): Winter Jacket: Rain Coat:

BSM/Ser 12/Effective 19.06.18/PDAF 5 of 5

You might also like