Personal questionnaire
PERSONAL DATA
Position Applied For:
*
Family Name:
*
Given Names:
Given Name 1:
*
Given Name 2:
Given Name 3:
Date of Birth:
*
Place of Birth:
*
Full Name & Surname of Parents:
Father's Name:
Father's Surname:
Mother's Name:
Mother's Surname:
Nationality:
*
Citizenship:
*
Marital Status:
*
Children Under age 18:
*
Religion:
*
Email Address:
*
Home Address:
*
Telephone Number:
*
Identity Number:
*
Next of Kin: (State address
only if different from above)
Relationship:
PERSONAL DOCUMENTS
Passport
*
*
*
*
Number
Place of Issue
Date of Issue
Date of Expiry
Seaman's Book
*
*
*
*
Number
Place of Issue
Date of Issue
Date of Expiry
Visa ( if any)
Number
Place of Issue
Date of Issue
Date of Expiry
Endorsements (if any)
Number
Place of Issue
Date of Issue
Date of Expiry
CERTIFICATES OF COMPETENCY
Main Certificate of Competency:
Number:
Date of Issue:
Date of Endorsement:
Other
Other Certificate of Competency:
Number:
Date of Issue:
Date of Endorsement:
STCW CERTIFICATES
Number
Date of Issue
Valid Until
Fire Fighting
Adv. Fire Fighting
First Aid at Sea
Ships Captain Medical
Pers. Safety & Survival Tech.
P.I.S.C
Tanker Certificate
GMDSS
Anchor Handling
Crane Handlling
Helicopter. U/Water Esc
Fast Craft Rescue
Other
HEALTH CERTIFICATE
Date of Last Examination
Date of Expiry
Medical:
*
*
*
Vaccination/Inocculations:
*
*
Drug & Alcohol Test Date:
EDUCATION
Name of School/College/University & Year Completed
Name:
*
Year Completed:
*
FORIEGN LANGUAGES
Good
Satisfactory
Poor
PREVIOUS PROVABLE SEA SERVICE PERIODS
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
Company
GT/HP
Vessel Name
Rank
Type
Eng Type
From Date
To Date
REASON/S FOR LEAVING LAST SEA GOING EMPLOYMENT
Reason:
CONTACT PERSONS FOR REFERENCE PURPOSES :
Name:
Company:
Telephone No:
Name:
Company:
Telephone No:
I certify that the details are correct