Sgoi Application Form 2024

Download as pdf or txt
Download as pdf or txt
You are on page 1of 8

SGOI-QMS-5A6-01-02

SYNERGYGROUP OPERATIONS INC.


PERSONAL DATA / APPLICATION FORM

Pass Fail

Tech/SI
Initials
Ops. Dept. Intro to Principal
___________________
Date Applied: Availability (Month): Email Address:
Present Rank: Higher License/No. Total Years in Rank:
MARINA SID No. E-Registration No. MISMO Acct No. (SRN)

Last Name: First Name Middle Name


June 2024 dcmate73@gmail.com
Chief Mate Master 15
Present Address: Contact No. Passport Size
Photo
Provincial Address: Contact No.

Date of Birth: (dd/mm/yy)


Joseph Age: Allan
Ralph Civil Status: FB Acct:
Cruz
Gender:
Place of Birth: B8 L2 Damascus St. Veraville Townhomes 2 09064517214
Skype ID: WhatsApp No.:

Interest/ Hobbies: MS Teams ID: Religion:

Course Finished: Year Attended Name of School:


From: To:
US Visa Validity: _______________ Height(ft):
SIRB No. Passport No. SSS No. ______________________ Weight(kg):
Date Issued: Date Issued: TIN No. ______________________ BMI:
Expiry Date: Expiry Date: PAG-IBIG No. _________________
Place of Issue: Place of Issue: PHILHEALTH No. _______________
Cuisine: (*for Chief Cook)
 Indian  Korean  Chinese  European Greek Others: __________

Next of Kin
Name: Date of Birth: Date of Anniversary:
Relationship: (*if married)

Address: Contact No. FB Acct: Total No. of Children:


Children Below 21 Years Old
Name Sex Date of Birth

Parents Details
Mother’s Maiden Name: Father’s Name:

Date of Birth: Date of Birth:

Place of Birth: Place of Birth:

Mother’s Contact Nos.: Father’s Contact Nos.:

Parent’s Home Address:

Page 1
SGOI-QMS-5A6-01-02

SYNERGYGROUP OPERATIONS INC.


PERSONAL DATA/ APPLICATION FORM
SEA-GOING EXPERIENCE
(most recent vessel first)
M.E. Make /
Trade Signed On Signed Off No. of Type of Cause of
Manning Agency Principal & Address Rank Vessel's Name Flag GRT DWT Model BHP or Nationality of other crew on board
Route (dd/mm/yy) (dd/mm/yy) Months Vessel Discharge
KW

2 of 4
SGOI-QMS-5A6-01-02

SYNERGYGROUP OPERATIONS INC.


PERSONAL DATA/ APPLICATION FORM
CERTIFICATION AND OTHER DOCUMENTS
DATE ISSUED EXPIRY DATE NUMBER VERIFIED
STCW CERTIFICATE OF PROFICIENCY (COP) (dd/mm/yy) (dd/mm/yy) SGO
BASIC TRAINING
SHIP SECURITY AWARENESS TRAINING AND SEAFARERS WITH DESIGNATED SECURITY DUTIES
PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOATS
ADVANCE TRAINING IN FIRE FIGHTING
PROFICIENCY IN FAST RESCUE BOATS
MEDICAL EMERGENCY FIRST AID
MEDICAL CARE
SHIP SECURITY OFFICERS COURSE
BASIC TRAINING FOR OIL AND CHEMICAL TANKERS
BASIC TRAINING FOR LIQUEFIED GAS TANKERS
ADVANCE TRAINING FOR OIL TANKERS
ADVANCE TRAINING FOR CHEMICAL TANKERS
ADVANCE TRAINING FOR LIQUEFIED GAS TANKERS
OFFICERS CERTIFICATE OF COMPETENCY (COC)
FOR MASTER (REG. II/2)
FOR CHIEF MATE (REG. II/2)
GMDSS (REG. IV/2)
FOR CHIEF ENGINEER (REG. III/2)
FOR SECOND ENGINEER (REG. III/2)
FOR DECK OIC (REG. II/1)
FOR ENGINE OIC (REG. III/1)
ELECTRO-TECHNICAL OFFICERS (REG. III/6)
RATINGS CERTIFICATE OF PROFICIENCY (COP)
RATINGS FORMING PART OF NAVIGATIONAL WATCH (REG. II/4)
RATINGS FORMING PART OF ENGINEERING WATCH (REG. III/4)
ABLE SEAFARER DECK (REG. II/5)
ABLE SEAFARER ENGINE (REG. III/5)
ELECTRO-TECHNICAL RATINGS (REG. III/7)
OTHER TRAINING CERTIFICATES (STCW/ IMO MODEL COURSES)
MANAGEMENT LEVEL DECK
SHIP SIMULATOR BRIDGE TEAMWORK WITH BRIDGE RESOURCE MANAGEMENT
MANAGEMENT LEVEL COURSE FOR DECK OFFICERS
ADVANCED TRAINING FOR SHIPS OPERATING IN POLAR WATERS
ICE NAVIGATION
OPERATIONAL LEVEL DECK
OPERATIONAL USE OF ECDIS (GENERIC) 2012 EDITION
BASIC TRAINING FOR SHIPS OPERATING IN POLAR WATERS
MANAGEMENT LEVEL FOR ENGINEER
ELECTRONIC ENGINE FAMILIARIZATION COURSE (ME-TYPE ENGINE)
MANAGEMENT LEVEL COURSE FOR ENGINE OFFICERS
MARINE HIGH VOLTAGE TRAINING
OPERATIONAL LEVEL FOR ENGINEER
ENGINE ROOM SIMULATOR COURSE WITH ENGINE ROOM RESOURCE MANAGEMENT
HYDRAULICS & PNEUMATICS
OTHER SPECIALTY TRAINING CERTIFICATES
GALLEY COURSES
SHIPS CATERING SERVICES (NC I) FOR MESSMAN
SHIPS CATERING SERVICES (NC III) FOR SHIP'S COOK (includes victualing)
PROVISION MANAGEMENT COURSE
TRADE TEST (INTERNATIONAL CUISINE)
SHIPBOARD CULINARY COURSE
HAZARD ANALYSIS AND CRITICAL CONTROL POINTS (HACCP) (Food Hygiene Course)
OTHER CUISINE/S: __________
FITTERS COURSES
SHIPBOARD WELDING COURSE
NC II: SHIELDED METAL ARC WELDING (SMAW)
TRADE TEST PREPARATION - MECHANICAL FITTER
ARC & GAS WELDING
LATHE MACHINE TRAINING
OFFSHORE SPECIALTY COURSES - OPITO
BASIC SAFETY INDUCTION & EMERGENCY TRAINING (BOSIET)
HELICOPTER UNDERWATER EMERGENCY TRAINING (HUET)-REGULAR
HELICOPTER UNDERWATER EMERGENCY TRAINING (HUET)-w/ EBS
HYDROGEN SULFIDE (H2S) - OPITO
COMPRESSED AIR - EMERGENCY BREATHING SYSTEM (CA-EBS)
HELIDECK EMERGENCY RESPONSE TEAM MEMBER (HERTM)
HELICOPTER LANDING OFFICER (HLO) - Deck Ofcrs/ABs
DANGEROUS GOODS by AIR AWARENESS (DG-A)
HELIDECK EMERGENCY RESPONSE TEAM LEADER (HERTL) -DeckOfcrs.
OTHER OFFSHORE SPECIALTY
CRANE OPERATOR COURSE - G20 / HYDRAULIC CRANE (for Deck ratings)
BASIC RIGGING AND SLINGING (for Deck ratings)
BASIC DYNAMIC POSITIONING (for JUNIOR OFFICERS)
ADVANCED DYNAMIC POSITIONING (for SENIOR OFFICERS)
DP MAINTENANCE (for Engineers)
COMPRESSOR MAINTENANCE (for Engineers)
K-POS SEISMIC MAINTENANCE
K-POS SEISMIC TRACKER
3 of 4
SGOI-QMS-5A6-01-02

SYNERGYGROUP OPERATIONS INC.


PERSONAL DATA / APPLICATION FORM

Shore Employment Details


DATE Nature of Employers Name Address and Contact Nos.
FROM TO Employment

Name: Job Position:


YES NO
1. Have you ever been denied entry to a particular country?
If yes, which country/ies?
2. Do you have any pending petition to migrate?
If yes, which country/ies?
3. Do you have any relatives who are citizen and/or residing/working abroad?
If yes, which country/ies?
4. Do you have pending/resolved cases in local or abroad, which may lead or has led to your
deportation or arrest?
If yes, which country/ies?
5. Are you POEA/DMW Watchlisted? (for reference in required contract processing time)

Declaration by the Applicant

I understand that a strict medical examination including Drug and Alcohol test as per company requirements is a
condition of my employment and I express my willingness to be examined.
I undertake to provide the company’s medical officer full details of my previous medical history.
I agree that the decision of the company medical officer is final.
I declare that there are no criminal/ police investigations in progress against me.
I confirm that all my travel documents are valid and in order. I understand that if my travel Documents become
invalid or restricted at any time during the course of my employment and cannot be revalidated by me under
normal process, the contract of employment will terminate, and all costs of repatriation will be borne by me. I
am /am not presently employed elsewhere.
I also declare that I have no past or present legal impediments that might stop me from working onward
company vessel.
I agree that previous employers may be contacted for information concerning my employment
record and hereby release them from any liability and confidentiality to provide such information.

Please attach photocopies of ALL certificates, passport, seaman’s book etc.

Printed Name with Signature Date

Page 4
SGOI-QMS-5A6-02-02

SYNERGYGROUP OPERATIONS INC.


MEDICAL HISTORY ASSESSMENT

Name: Rank:
Last Name First Name Middle Name

Reason for Last Repatriation: [ ] End Contract [ ] Accident [ ] Sickness

If Accident or Sickness: When Where


Please Specify: _________
MEDICAL HISTORY - Please put a check mark under Yes if you have ever suffered from or have been told that you have had the following
conditions, if not please put a check mark under No.

YES NO YES NO YES NO


1. Nose or throat trouble 12. Cancer or tumor 23. Sexually transmitted disease
2. Ear trouble or deafness 13. Mental disorder 24. Genetic of familial disorder
3. Chronic cough 14. Head or neck injury 25. Operations
4. Asthma 15. Hernia (rupture) 26. Malaria, if yes, date of last attack
5. Tuberculosis 16. Rheumatism, joints or back trouble 27. Tropical disease
6. Other lung disease 17. Fainting spells, fits or seizures 28. Frequent headache
7. High blood pressure 18. Typhoid or paratyphoid fever 29. Dizziness
8. Heart trouble 19. Trachoma or other eye trouble 30. Allergy
9. Rheumatic fever 20. Stomach pain or ulcer 31. HEPA B
10. Diabetes mellitus 21. Other abdominal trouble 32. Any intake of medication for
11. Endocrine disorder 22. Kidney or bladder trouble treatment of illness/es
Others: Please use Remarks Section
Do you have a history of Medical Repatriation/ medical issue prior disembarkation? If yes, pls specify.

REMARKS:

Last Recruitment Agency: Contact


Person:
Date of Last Medical Examination: Clinic:
Be honest and truthful with your HEALTH DECLARATION (POEA Standard Terms & Condition)

Signature of Seafarer over Printed Name


SGOI-QMS-5A6-03-01

SYNERGYGROUP OPERATIONS INC.


BACKGROUND ASSESSMENT OF SEAFARER

DATE: _________________

TO : ___________________________________
ATTENTION : ___________________________________

Dear Sir/Madam

I hereby authorize SYNERGYGROUP OPERATIONS, INC. to conduct a background check from your good
office to ascertain my experience and suitability for employment.

Very truly yours,

____________________________________
(Rank/Name of Seafarer)
============================================================================================================================================

For SGOI evaluation, may we request for your comment/s based on the criteria below and kindly return it to us
through electronic means.
Any and all information given will be treated strictly confidential.

Thank you very much.


SGOI Operations Department

ASSESSMENT

5 – Very Good 4 – Good 3 – Satisfactory 2 – Fair 1 - Poor


ABILITY
CONDUCT
HEALTH
SOBRIETY
INTERPERSONAL RELATIONS
ATTITUDE TOWARDS WORK

Do you recommend Seafarer for re-employment? YES NO

Reason for Repatriation (Please tick):

End of Contract Sickness Change Principal/Vessel


Dismissed Own Request Others__________________

Has the Seafarer been involved in any Medical cases Yes


Doctor’s Visit during Employment? If yes, please give details under Other Comment. No
Other Comments:

Name of Interviewer: _____________________________________


Designation : _____________________________________
Signature : _____________________________________
SGOI-QMS-5B6-01-01

SYNERGYGROUP OPERATIONS INC.


DATA PRIVACY STATEMENT

Synergygroup Operations Inc. (SGOI) aims to comply with the Data Privacy Act of 2012 (DPA) and cooperate fully with the National
Privacy Commission (NPC). This Privacy Statement describes how SGOI collects, uses, and discloses certain personal information
obtained through your engagement of our services for:
- Job Application
- Documents Submission as required for Recruitment and Selection Process
- Job Offer
- PEME as required by DOLE
- Training requirements
- Insurance coverages / Compensation and Benefits Process
- Tax information
- Payroll management and social benefits and performance monitoring and

This Privacy Statement does not address information collected through other sources such as personal contacts.

A. Personal Information Collection and Use


We collect your personal data that comprise those that you may have provided to us, which includes but not limited to, your name, e-
mail address, phone number, address, and such other personal information (collectively referred to as “Personal Information”) in your
Engagement with us. We retain and process your Personal Information to enable us to pursue your job placement, provide our services
to you, administer any contract for goods and/or services that we may have with you, correspond with you in the course of your
recruitment up to employment process and records keeping, and provide you with relevant event materials, for your information
(collectively referred to as "Purpose").

B. Data Sharing and International Data Transfers


We use and share your information as permitted or required by law to pursue our legitimate interests as a Seafarer Recruitment and
Placement Service agency. We may also share and/or transfer Personal Information with other persons for purposes of responding to
your requests, in relation to your job application or as otherwise necessary for the Purpose and Engagement described above. We may
also, in limited circumstances, share Personal Information with government authorities or others as required to protect the interests of
SGOI or others, or as required by applicable law or court order.

C. Data Protection
We shall implement reasonable and appropriate organizational, physical, and technical security measures for the protection of personal
data which we collected. The security measures shall aim to maintain the availability, integrity, and confidentiality of personal data and
are intended for the protection of personal data against any accidental or unlawful destruction, alteration, and disclosure, as well as
against any other unlawful processing. We only permit your data to be accessed or processed by our authorized personnel who hold such
information under strict confidentiality. We restrict access to information to just anyone who like to know/obtain such information
without justifiable ground.
Any data security incident or breach that comes to the knowledge of the SGOI will be recorded and reported as required by law. SGOI
will take all necessary and reasonable steps to address such incident or breach and mitigate any negative effect of such incidentor breach.
If there is strong suspicion that an incident affects your personal information, SGOI will notify you of such incident in an appropriate
manner.

D. Access and Correction


If you wish to access, correct, limit, or update the Personal Information you have submitted to us, or to make any inquiries or
complaints about the processing of such information, please contact us by sending an email to dpo@synergygroup.ph

E. Retention Period
We retain your Personal Information for as long as reasonably necessary for and/or relevant to business activities related to the
Purpose. Kindly note that it will be necessary for SGOI to process your Personal Information for the Purpose, without which we will not
be able to carry out the Purpose.

F. Confidentiality
Our employees shall operate and hold personal data under strict confidentiality. They are required to sign non-disclosure agreements
and have received training on the company’s privacy and security policies to ensure confidentiality and security of personal data.

G. Right to Privacy
As provided by the DPA, you may object to the processing of your personal data, request to access your personal information, and/or have
it corrected, erased, or blocked on reasonable grounds. For the details of your rights as a data subject, you can get in touch with our Data
Privacy Officer or at National Privacy Commission at https://privacy.gov.ph/. SGOI will consider your request and reserves the right to
deal with the matter in accordance with the law.

H. Privacy Violations
If you reasonably believe that we have committed any violation of your rights as a data subject and/or of applicable data privacylaws,
you may contact us by sending an email to dpo@synergygroup.ph.
SGOI-QMS-5B6-01-01

SYNERGYGROUP OPERATIONS INC.


DATA PRIVACY STATEMENT

I. Contact Information
If you have further questions or concerns regarding your privacy rights, this Consent Form or any matter regarding the Data PrivacyAct of
2012, you may contact our Data Protection Officer through the following details:

The Data Protection OfficerTel.


No.: (02) 85383456

Email Address: dpo@synergygroup.ph

CONSENT

By accepting the Data Privacy Statement, I, ______________________________________________ (as "Data


Subject") grant my, voluntary and unconditional consent to the collection and processing of all Personal Data, and account or
transaction information or records (collectively, the "Information") relating to me disclosed/transmitted by me in person or by my
authorized agent/representative/s to the Synergygroup Operations Inc. (SGOI) and/or any of its authorized agent/s or
representative/s as Information controller, by whatever means in accordance with Republic Act (R.A.) 10173, otherwise known as
the "Data Privacy Act of 2012" of the Republic of the Philippines, including its Implementing Rules and Regulations (IRR) as well as
all other guidelines and issuances by the National Privacy Commission (NPC).

I acknowledge and agree that SGOI may share these data between them and such data may constitute my personal or sensitive
personal information (which includes without limitation, my name, address, gender, age, marital status, contact details, birthday,
SSS, TIN, education, employment information, financial information, medical information, spouse details, preferences, behavior,
and other information classified as "personal data," "personal information," or "sensitive personal information" under the Data
Privacy Act), as well as information relating to my accounts, transactions and communications with my principal employer or to
any person, entity or body in relation to my work. Said data may be collected, processed, stored, updated, or disclosed by SGOI in
accordance with its Data Privacy Notice. My information may continue to be collected, stored, processed and/or shared between
and among thepersons, entity or body until deemed necessary.

I also acknowledge and warrant that I have acquired the consent from all parties relevant to this consent and hold free and
harmless and indemnify SGOI, its directors, officers, employees and its principals from any complaint, suit, or damages which any
party may file or claim in relation to my consent.

I also acknowledge and consent that SGOI will also record my personal information for purposes of record-keeping. Further, I
understand that I may access, update, or correct certain personal information, or withdraw consent to the use of any of my
information as set out in this letter at any given time by communicating with SGOI’s Data Protection Officer.

I hereby acknowledge that I have been provided with the written notification on my/our rights as a Data Subject (each, a "Right",
collectively, the "Rights").

I have read this form, understood its contents and consent to the processing of my personal data. I understand that my consent
does not preclude the existence of other criteria for lawful processing of personal data and does not waive any of my rights under
the Data Privacy Act of 2012 and other applicable laws.

_______________________________________
Signature above printed name
Date: ______________________________

You might also like