Safety Officer Seaman

BSM/Ser **/Effective **.**.**/PDAF

PERSONAL DATA/APPLICATION FORM

BSM Crew Service Centre Philippines, Inc.

S

Rank/Position Applied For: Last Name: First Name Middle Name

Home Address: Tel. No.

Contact Address:

Cell No.

Email add:

Place of Birth:

Civil Status:

Wedding Date:

Course Finished:

Year Attended Name of School:

From:(dd/mm/yy) To: (dd/mm/yy)

Interests/Activities/Hobbies:

Languages Spoken (pls. check all applicable

choices):

English

Filipino

Others

For Office Staff Use Only:

IHTS Height: Cm

Blood Pressure: Weight: Kg

Religion: BMI:

SSS No.: TIN No.: PAG-IBIG No.: PHILHEALTH No.:

Cholera Exp.: Yellow Fever Reference No.:

Year Started Seagoing

Employment:

Years in Present Employment:

Next of Kin

Name: Date of Birth (dd/mm/yyyy): Relationship:

Address:

Telephone No.:

Children Below 21 Years Old

Name Sex Date of Birth (dd/mm/yy)

Total No. of Children:

Parents Details

Mother’s Maiden Name:

Date of Birth:

Father’s Name:

Date of Birth:

Home Address:

Pass Fail

Recruitment

Initials

Ops. Dept. Intro to Principal

Passport Photo

Previous Salary:

Salary Expectation:

Foreign Principal &

Address

Local Agency Rank Vessel's Name & Flag Trade Route Signed on

(dd/mm/yy)

Signed off

(dd/mm/yy)

No. of

Months

Type of

Vessel

DWT &

GRT

M.E. Make BHP or KW Cause of Discharge

Nat. of

Master/Offs

Nat. of

Ratings

BSM/Ser 08/Effective 21.01.13/PDAF 2 of 5

SEA-GOING EXPERIENCE

(most recent vessel first)

DATE ISSUED EXPIRY DATE LEVEL NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

CERTIFICATE OF COMPETENCY (OFFICERS)

CERTIFICATE OF ENDORSEMENT (OFFICERS)

CERTIFICATE OF PROFICIENCY (NWK / EWK)

CERTIFICATE OF PROFICIENCY (ABLE SEAFARER)

BOARD LICENSE

NC I - NC III

SEAMAN'S BOOK

PASSPORT

U.S. VISA

POEA E-Registration (ERN)

GOC

DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

BASIC SAFETY COURSE

COP BT

ADVANCE SAFETY COURSE

CoP Advanced Training in Fire Fighting

CoP Proficiency in Survival Craft & Rescue Boat

CoP Medical Emergency - First Aid

CoP Medical Care

CoP Proficiency in Fast Rescue Boat

TANKER TRAINING CERTIFICATES

CoP Basic Training Oil/Chemical Tanker

CoP Basic Training Liquefied Gas Tanker

CoP Advanced Training in Oil Tanker

CoP Advanced Training in Chemical Tanker

CoP Advanced Training in Liquified Gas Tanker

NAVIGATIONAL

CoP Ship Security Officer

CoP SDSD / SAT

Safety Officer Course

ECDIS (Generic)

ECDIS (Specific)

BSM/Ser 09/Effective 19.06.18/PDAF 3 of 5

CERTIFICATION AND OTHER DOCUMENTS

LICENSES AND DOCUMENTS

NATIONAL CERTIFICATIONS

VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

SEAMAN'S BOOK

ENDORSEMENT / LICENSE

GOC / GMDSS ENDORSEMENT

OTHER CERTIFICATES:

1

2

3

VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

SEAMAN'S BOOK

ENDORSEMENT / LICENSE

GOC / GMDSS ENDORSEMENT

OTHER CERTIFICATES:

1

2

3

VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

SEAMAN'S BOOK

ENDORSEMENT / LICENSE

GOC / GMDSS ENDORSEMENT

OTHER CERTIFICATES:

1

2

3

VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

SEAMAN'S BOOK

ENDORSEMENT / LICENSE

GOC / GMDSS ENDORSEMENT

OTHER CERTIFICATES:

1

2

3

VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED

(dd/mm/yy) (dd/mm/yy) (BSM use only)

SEAMAN'S BOOK

ENDORSEMENT / LICENSE

GOC / GMDSS ENDORSEMENT

OTHER CERTIFICATES:

1

2

3

BSM/Ser 08/Effective 27.05.19/PDAF 4 of 5

CERTIFICATION AND OTHER DOCUMENTS

FLAG DOCUMENTS & CERTIFICATES

BSM/Ser 12/Effective 19.06.18/PDAF 5 of 5

BSM Crew Service Centre Philippines, Inc.

S

WORKING EXPERIENCE (pls. check all applicable)

WATER TUBE BOILERS

DUAL EVAPORATION BOILERS

THERMAL OIL BOILERS

MEDIUM SPEED ENGINES

SLOW SPEED ENGINES

ELECTRIC WELDING

GAS WELDING

ELECTRONICS

AUTOMATION

FRAMO PUMPS

SUBMERSIBLE PUMPS

CRUDE OIL WASHING

HEAVY LIFT OPERATORS

COMPUTERS

HYDRAULIC POWER PACKS

SATELLITE TELEX

RADIOTELEX

ETHYLENE OPERATIONS

DECK CRANES

OBO OPERATION

INERT GAS SYSTEMS

REEFER CONTAINERS

DERRICKS

TURBO GENERATORS

BOW THRUSTER

Shore Employment Details

DATE

Nature Of Employment

FROM TO Employers Name and Address

Working Gear Size

Collar (Cm): Chest (Cm): Waist (Cm):

Shoes (Cm): Winter Jacket: Rain Coat:

DECLARATION

I certify that the above information is true and accurate. No Certificate of Competence or License issued to me has ever been revoked or suspended. Any false information would lead to denial of application. I agree that during this application process I will be subjected to a computer based Professional and English Language assessment test. The results of which is form part of this application. I hereby confirm that I had no jail term and not admitted to a mental institution prior employment via BSM Crew Service Centre Philippines, Inc.

I hereby confirm that I was never repatriated on medical grounds nor ever involved in an accident on board nor ever required medical treatment following contract completion. I hereby confirm that I had no past history of any serious medical condition which will affect my work ability at sea.

I hereby confirm that I had not taken any disability compensation from any employer in the past due to a condition which permanently affect my ability to work at sea. Signature

Date

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