APPLICATION FORMIssued by: QMR Eff. Date: 31-01-14 Revision: 02 Page 1 of 2 7.5-1

Application Date (dd-mm-yyyy): ______________________ EX - CREW NEW CREW

A. PERSONAL DETAILS:LAST NAME: MOTHER’S MAIDEN NAME:

PHOTO

FIRST NAME:MIDDLE NAME: FATHER’S NAME:BIRTH DATE (dd-mm-yyyy):

BIRTH PLACE: RELIGION:AGE: MOBILE NUMBER:MARITAL STATUS:HOME ADDRESS:CITY ADDRESS:AVAILABILITY: Height (cm) : Weight (kg):

SSS No.: - - POSITION:Phil-Health No: - - LICENSE HELD:Pag-ibig No.: - - HIGHEST EDUCATIONAL ATTAINMENT:TIN No.: - -

RECOMMENDED BY:SCHOOL:YEAR GRADUATED:

B - 1. SEAFARER’S DOCUMENTS / TRAINING CERTIFICATES:

DOCUMENT NAME NUMBER PLACE ISSUED DATEISSUED EXPIRY

Seaman’s Book (SIRB)PassportUS Visa SRCYellow feverNBI ClearanceMARINA – COCMARINA – EndorsementSTCW Regulation (As on EOC) Limitations (if any)

MARINA – GOC (Deck Officers Only)

TESDA COP – (NC I / NC II)MARINA COP – (Deck / Engine) – IVMARINA COP – (Deck / Engine) - VMarshall Islands SBKMarshall Islands EndorsementMalta SBKMalta EndorsementCyprus SBKCyprus EndorsementHong Kong Endorsement

B - 2.A SEAFARER’S DOCUMENTS / TRAINING CERTIFICATES: *** Please put a check ( ) if you have the TRAINING CERTIFICATE and MARINA COP for the below mentioned courses. Kindly indicate the validity of MARINA COP’s. ***

TRAINING CERTIFICATE NAME With Training Certificate MARINA COP

DATE (for MARINA COP’s)ISSUED EXPIRY

Basic Training (BT)Proficiency in Survival Craft and Rescue Boats (PSCRB)Proficiency in Fast rescue Boats (PFRB)Advance Training in Fire Fighting (AFF)Medical First Aid (MEFA)Medical Care (MECA)Basic Training for Oil & Chemical Tanker (BTOC)Ship Security Officer (SSO)Seafarers with Designated Ship Duties (SDSD)Deck / Engine Watchkeeping Training Certificate

B – 2.B *** Please put a check ( ) if you have the TRAINING CERTIFICATE ***

APPLICATION FORMIssued by: QMR Eff. Date: 31-01-14 Revision: 02 Page 2 of 2 7.5-1

TRAINING CERTIFICATE NAME ( ) TRAINING CERTIFICATE NAME ( )

FOR DECK OFFICERS: FOR GALLEY:Ship Safety Officer Course Messman / Steward CourseBridge Resource Management / (BTM) Culinary / Catering CourseShip Simulator with Bridge Teamwork OTHER CERTIFICATES:Global Maritime Distress and Safety System Risk Assessment Management (RAM)Ship's Restricted Radiotelephone Operator's Course Risk Assessment and Incident Investigation Analysis INMARSAT / SATCOM Maritime LawCollision Avoidance Bilge Water / Waste Oil ManagementRadar Observer’s Course / Radar Observer’s Plotting Hazardous MaterialRadar Simulator Course PADAMSAutomatic Radar Plotting Aids Maritime EnglishAutomatic Identification System OTHER CERTIFICATES PLEASE SPECIFY:Electronic Chart Display and Information SystemShip Handling and Maneuvering Cargo Handling and Care of Cargo

FOR ENGINE OFFICERS:Engine Resource Management / (ETM)Engine Simulator Course / (ERSM)Control EngineeringHydraulics / PneumaticsAuxiliary Machinery System

C. SEA SERVICE:

VESSEL NAME AGENCY TYPE Engine TYPE RANK DATE MonthsFLAG PRINCIPAL GRT BHP Sign On Sign Off Reason

D. NEXT OF KIN / DEPENDENTS

NAME RELATIONSHIP TO SEAFARER GENDER ADDRESS DATE OF

BIRTH CONTACT DETAILS

“ I hereby authorize CREWBENEFIT, INC. to treat all the information I have declared herein with confidentiality. All information cannot be disclose, publish, or reveal without my specific authorization. I also understand that any misrepresentation or false statement declared herein shall be caused for denial of my employment. “

SEAFARER’S SIGNATURE OVER PRINTED NAME / DATE