CRW13 – APPLICATION FOR EMPLOYMENT

Page 1 of 2 CRW13 – Application Form Revision Number: 4.1 File Ref: Office File: 11B

Home Address

Personal Documents Issued on Valid until Passport (Country / Number)

Seaman’s book

USA C1/D visa

Telephone

Schengen Visa

E-Mail

Medical Fitness Certificate

National Certificates of Competence

country_______________________ Tanker Endorsements

Management level □ Operation level □ Grade Issued Expires Oil Chemical Gas

Valid Flag State Endorsements

Liberia , Panama , Malta , Marshall Islands , UK □, Singapore Norway (DIS) , Other (list flags)

GMDSS General /Restricted

Flag State GMDSS Endorsements (list)

Other valid certificates and training attended

Basic Safety Training Advanced Fighting Medical First Aid Medical Care ECDIS (generic) ECDIS (type specific) Bridge Team Management Ship Handling Liquid Cargo Handling ER Management Other (specify)

Please answer the following questions: Did you suffer, or presently suffer from any disease likely to render you unfit for services at sea or

likely to endanger the health of other persons on board? If yes, please provide details ________________________________________________________ _______________________________________________________________________________

YES NO

Did you suffer any accident, which rendered you temporary and/or partially disabled? YES NO Did you ever undergo psychiatric treatment YES NO Are you addicted to alcohol or drugs of any kind? YES NO

I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organization. Place___________________________ Date ___________________________ Signature ______________________________

For Office Use Initial assessment of applicant for further recruitment Comments ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ MSO responsible person Name / Signature _______________________________________________ Date ________________________________

Personal Data

AFFIX HERE YOUR RECENT PASSPORT SIZE PHOTOGRAPH

First Name

Middle Name Last Name / Surname

Nationality Date Of Birth (dd/mm/yy) Place of Birth

Position Applied For □ Female □ Male Available date

CRW13 – APPLICATION FOR EMPLOYMENT

Page 2 of 2 CRW13 – Application Form Revision Number: 4.1 File Ref: Office File: 11B

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

Company Flag Vessel Name Type (1) GRT DWT Main Engine (2) BHP Rank Date From (dd/mm/yy)

Date To (dd/mm/yy)

Reason for S/off (3)

(1) Use only the following abbreviations for vsl types: (2) Engineers to give make/model of engines, e.g. “MAN 14V52/55A” or “SULZER 5RTA58” (3) Reason of Sing Off, e.g. “EOC – End of Contract”, “MED – Medical Ground”, “OWN – Own request”

Please provide details of two recent employers who we may contact for references

Name of Company Name of person to contact Address

Telephone/E-Mail

*Please use only following abbreviations for the vessel type: GCD General Cargo MLP Multi-Purpose B/C Bulk Carrier CON Container O/O Ore Oil OBO Ore/Bulk/Oil TNC Tanker Crude TNP Tanker Product FSO / FPSO TNV VLCC/ULCC LPG CHM Chemical Tank PAS Passenger Ship R/O Ro/Ro LSH Lash DRG Dredger OSV Offshore Supply LNG SRV Survey vessel LOG Log/Timber NVL Naval Ship SSHL Semi-Submergible Heavy Lift MOB Mobile Offshore Unit

Other Personal ID/ Documents/ Visa

Type of Document / ID Rank No. Date of Issue (DD/MM/YY)

Issued at (Place) Valid Until

(DD/MM/YY) Philippine License P.R.C. Endorsement COC Officers Ratings Type: GOC Others:

(PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM.)

Name of Crew:

Other Personal Data

Alternative/Temporary Address: Until:___ / ____ / ____

Post Code: Marital Status1: Referred by:

Cellphone: Religion 1Select From : ·Single ·Married ·Divorced ·Common Law Partner ·Widowed ·Separated (Please Specify)

Other Personal ID/ Documents/ Visa

Type of Document / ID Country of Issue No. Date of Issue (DD/MM/YY)

Issued at (Place) Valid Until

(DD/MM/YY) Yellow Fever vaccination

S.R.C Rating:

Liberian Seaman Book

Panamanian Seaman book

Others:

SOCIAL SECURITY (S.S.S.) Number: Place issue:

PAGIBIG Number: Place issue:

Personal Tax (T.I.N.) Number: Place issue:

PHILHEALTH Number: Place issue:

2Select From : ·Spouse ·Partner ·Child ·Parent ·Grand Parent ·Other Relative (Please Specify)

Nominee / Next of Kin & Family Details Full Name of Nominee for compensation in case of fatality: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Relationship 2 _ _ _ _ _ _ _ _ _

Gender : Male Female

Nationality:

CHECK THE BOX IF THE NOMINEE/NEXT OF KIN HAVE SAME ADDRESS AS ABOVE Date of Birth (DD/MM/YY) : Address: City: Post Code: Country: Email: Tel: Mobile:

Family Data 2:

Relationship First Name Last Name Date of Birth (DD/MM/YY) Contact No. (if any)

Spouse / Partner Child M F Child M F Child M F Child M F Child M F

Pacific Ocean Manning Inc. DATE OF APPLICATION:

MPS NO.

PCN NO.

CREW PERSONAL INFORMATION FORM

Issue Date: 27 Feb. 2014 Form No: OPS 05 Rev. Date/ No : 28 July 2015 / 2

CRITERIA FOR EXAMINATION PASS: Seafarers achieving an overall score of 70% or more and achieving a score of 60% or more in each category. Master/Deck officers must achieve a score of 80% or more in the “Detailed Test’ in navigation.

Test Result: _____________________________ Date Performed: _______________________________

Family Data 1: LAST NAME FIRST NAME MIDDLE NAME Date of Birth (DD/MM/YY)

Mother’s Maiden Name (KADALAGAHAN) Father’s Name

Educational Background

Educational Attainment: School:

Year Graduated: Languages Spoken :