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    QMP FORM NO - 18 (Seafarer Recruitment Application Form) (2) 27.10.2022

    Uploaded by

    saiful
    The document appears to be an application form for crew positions, as it requests information such as education history, sea experience, certifications held, family details, references, and a declaration signed by the applicant. The form collects personal details, documents, qualifications, and sea service history to evaluate applicants for crew jobs. It requests identification documents, medical certifications, training certificates, records of previous vessels served on, and references from past employers.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    QMP FORM NO - 18 (Seafarer Recruitment Application Form) (2) 27.10.2022

    Uploaded by

    saiful
    61 views4 pages
    The document appears to be an application form for crew positions, as it requests information such as education history, sea experience, certifications held, family details, references, and a declaration signed by the applicant. The form collects personal details, documents, qualifications, and sea service history to evaluate applicants for crew jobs. It requests identification documents, medical certifications, training certificates, records of previous vessels served on, and references from past employers.

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    Original Title

    QMP FORM NO- 18 (Seafarer recruitment Application form)(2) 27.10.2022

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    The document appears to be an application form for crew positions, as it requests information such as education history, sea experience, certifications held, family details, references, and a declaration signed by the applicant. The form collects personal details, documents, qualifications, and sea service history to evaluate applicants for crew jobs. It requests identification documents, medical certifications, training certificates, records of previous vessels served on, and references from past employers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    61 views4 pages

    QMP FORM NO - 18 (Seafarer Recruitment Application Form) (2) 27.10.2022

    Uploaded by

    saiful
    The document appears to be an application form for crew positions, as it requests information such as education history, sea experience, certifications held, family details, references, and a declaration signed by the applicant. The form collects personal details, documents, qualifications, and sea service history to evaluate applicants for crew jobs. It requests identification documents, medical certifications, training certificates, records of previous vessels served on, and references from past employers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 4

    Revision No: 00

    Issue Date: 12.07.2022


    Page Page 1 of 4
    MSM-CREW-F-18-R0

    CREW MANNING AGENCY QUALITY MANUAL (FORMS)

    PHOTO

    APPLICATION FORM
    1 Position
    Position applied for:
    Are you willing to accept any other positions?
    If YES, which positions would you consider?
    Readiness From

    2 Personal details
    Last Name: First Name: Middle Name:
    Date of birth Place of birth Nationality
    Height Weight ID Mark NIL Blood Group
    Chest Waist Boiler Suite Safety Shoe Cap
    National ID SKYPE ID Company ID
    Address:

    Post code: Hand Phone No.


    Telephone No. E-Mail ID:

    3 Education Background
    Name From Year To Year Highest Qualification Attained
    School
    College
    Pre Sea Training
    Other Qualifications

    4 Identity documents
    DOCUMENT COUNTRY NUMBER ISSUE DATE PLACE
    Passport: Bangladesh
    Seaman’s book: National
    Bahamian
    Liberian
    Panamanian
    Other -Norway
    Seaman ID Card YES / NO
    Visa – US ‘C1/D’ YES / NO
    Other Visa YES/NO
    Yellow Fever Vaccination YES / NO
    Holding Australian MCV YES / NO
    5 Family details
    Revision No: 00
    Issue Date: 12.07.2022
    Page Page 2 of 4
    MSM-CREW-F-18-R0

    CREW MANNING AGENCY QUALITY MANUAL (FORMS)

    Next Of Kin / Nominee Marital Status : Relationship : Marriage Date :


    Last Name: First Name
    Address:
    Post code:
     Hand Phone No. Telephone No.
    Relation Name P.O.B. D.O.B. PPT NO. D.O.I. P.O.I. D.O.E.
    WIFE
    SON
    DAUGHTER

    Note: Second Next Of Kin / Nominee (In case of voyage with family)
    Relation Name
    Address:
    Mother’s Name
     Hand Phone No. Telephone
    No.

    6 National Certificate of Competency (Highest certificate of competency held)


    Class/Grade Issuing Country Certificate No. Date Issued Place Issued Valid Until
    CLASS-1 (DECK)
    GMDSS
    GMDSS ENDRS.

    6a National Dangerous Cargo Endorsements


    Endorsement Type Certificate No. Date Issued Place Issued Valid Until

    Petroleum
    Liquefied Gas
    Chemicals

    7 Flag State Equivalent Certificates Of Competency issued by other countries (Issued by countries other than in Section 6)
    Class Issuing Country Certificate No. Date Issued Place Issued Valid Until
    Liberia
    Panama
    Bahamas

    7a Flag State Equivalent Dangerous Cargo Endorsements (Issued by countries other than in Section 6a)

    Country Endorse Type/ Level Certificate No. Date Issued Place Issued Valid Until
    Liberia
    Marshall Islands
    Panama

    8 Certificates ( STCW and Value added)


    Revision No: 00
    Issue Date: 12.07.2022
    Page Page 3 of 4
    MSM-CREW-F-18-R0

    CREW MANNING AGENCY QUALITY MANUAL (FORMS)

    Course Institution Place Issue Date Cert. No. Expiry Date


    Personal Survival Techniques
    Basic / Advance Fire Fighting
    Elementary / Medical First Aid
    Capt’s Medical Guide/ Medical Care
    Proficiency In Survival Craft & RB
    Human Relations – PSSR
    Automatic Radar Plotting Aid (ARPA)
    Electronic Navigation System
    Navigation Control
    Ship Security Officer
    Tanker Familiarization (Oil,Chem,Gas)
    Advance Oil Tanker Safety
    Advance Chemical Tanker Safety
    Advance Gas Tanker Safety
    Liq. Cargo Handling Simulator
    Bridge Resource Management
    Bridge Team Management
    Marine Environment Protection
    Ship Manoeuvring /Handling Simulator
    Hazardous Materials
    Ship Board Safety Officers
    Elect. Chart Display & Info System

    9 Record of previous service


    (Please give a full record starting with the last vessel on which you served)

    Company Vessel Name Type Flag GRT/ Rank Sign On Sign off Duration
    DWT date date

    10 References (Please give the name and address of your current or immediate past employer)
    Name of Company
    Name of person to contact
    Address

     No. / Facsimile
    E-Mail / Website
    11 Miscellaneous (Please give the details of your FC account)
    Name of Bank Branch
    Revision No: 00
    Issue Date: 12.07.2022
    Page Page 4 of 4
    MSM-CREW-F-18-R0

    CREW MANNING AGENCY QUALITY MANUAL (FORMS)

    Account Name
    Address

    Account No. Swift / BIC Code

    12 Declaration
    I hereby declare that the above particulars are true and authorise you to contact the referees listed above.

    Name/Signature Date

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