test | Cenmar Manila

APPL-01 rv22

SEAMAN’S APPLICATION FORM

Recent colored photo, passport size:

Position applied for

Expected readiness

Surname *	First name *
Date of birth	Place of birth
Height	Weight
Nationality *	Address
Phone Nr	Phone mobile
E-mail *	Gender
Father’s name	Mother’s name
Next of kin, full name & relation	Next of kin, tel.

Grade / Level	Name of School Attended	Year Completed
Elementary
High School
College
Highest Educational Attainment (Degree)
B.S.

Name	Rank	Number	Date of issue	Date of expire	Place of issue
License / COC

Name	Number	Date of issue	Date of expiry
GOC IV/2 (GMDSS)
Basic Training for Oil & Chemical Tanker Cargo Operations (BTOC) – REG V/1-1
Advanced Training for Oil Tanker Cargo Operations (ATOT) - REG V/1-1
Advanced Training for Chemical Tanker Cargo Operations (ATCT) - REG V/1-1
Advanced Fire Fighting REG VI/3
Basic Safety Training VI/1
Survival Craft & Rescue Boat Other Than FRB – REG VI/2
Medical Care - REG VI/4.2
Medical First Aid - REG VI/4.1
SSO - REG VI/5
SDSD - REG VI/6
BRM-BTM
ERM
ECDIS GENERIC
ECDIS SPECIFIC
Safety Officer
FREE-FALL LIFEBOAT (COXSWAIN)
FAST RESCUE BOATS
Flag Endorsement (i.e Marshall Islands, Malta)

Name	Item done	Item due	Place of issue
Yellow Fever
COVID-19

* only for deck officers | ** only for engine officers | *** only for deck/engine officers (Pumpman / COP-Framo)

Who referred you in CENMAR?

Relation

I, the undersigned, confirm that all details provided on this form are correct.

Seafarer's Signature

Date

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