Document : Crew Manning
Issued By : Crew Manager
Title : Employment Application For Ship Personnel
Documation : IST-106
Approved
: General Manager
Part : 3
ISM Kod 6.0
Application Form
FORM IST 106-3
[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]
Individual’s Code Number
1.
Personal Data
First Name
Middle Name (s)
Nationality (or current
Citizenship )
Country of Origin
Date of Birth:
AFFIX YOUR
RECENT
PASSPORT SIZE
PHOTOGRAPH
HERE
Place / City of Birth
(DD / MM / YY)
Marital Status1:
1Select
Last Name / Surname
Gender :
Religion:
Christian
Male
Female
from : ●Single ●Married ●Divorced ●Common Law Partner ●Widowed ●Separated
Rank applied for:
Available
Willing to accept lower rank? Yes
From
(date):
(DD / MM / YY)
No
Primary / Permanent Address:
Alternative / Temporary Address:
Until: ____ / ____ / ___
13D/4 BEACH ROAD
City:
Post Code:
City:
Post Code:
State :
Country :
State:
Country
Nearest Airport :
Home Tel:
Phone:
Mobile Tel .
Fax:
Email:
Contact Method :
Collar:
cm
Email
Chest:
Fax
cm
Specify size as S, M, L, XL, XXL for :
2.
Waist:
Mobile Phone
Home Phone
Inside Leg:
cm
Sweater size:
cm
Boiler suit size:
Cap:
Post
cm
Shoes Size:
Personal ID / Documents / Visa
Type of Document / ID 1
Country of Issue
Date of Issue
(DD / MM / YY)
No.
Issued at (Place)
Valid Until
(DD / MM / YY)
Seaman’s Book (National)
Passport
National Seaman ID
CoC
Medical Examination
Yellow fever
US Visa C1/D
Schengen Visa
Other ................................
GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO
Social Security
Number:
Issuing Country
Personal Tax
Number:
Issuing Country:
1
Select as applicable: ●Passport ●Seamans Book ●Seaman Passport ●Seafarers’ Identity Document ●Registration Book ●National ID Card ●PAGIBIG Housing Insurance ●Health Insurance ●Overseas Emp Cert ●PHL Card ●Pension Fund ●Provident Trust ●Professional Organisation ●Driving Licence
●Visa ●Vaccination ●Yellow Fever.
Established Date : 15.10.2012
Page No : 1/6
Rev. No : 6
Rev. Date : 30.04.2014
Document : Crew Manning
Issued By : Crew Manager
Title : Employment Application For Ship Personnel
Documation : IST-106
Approved
: General Manager
Part : 3
ISM Kod 6.0
Nominee / Next of Kin & Family Details
3.
Full Name of Nominee for compensation in case of fatality:
_______________________________
Relationship1
________
Gender :
Nationality :
Female
Address:
1
City:
Post Code:
Country:
Email:
Tel:
Mobile:
Select From : ●Spouse ●Partner ●Child ●Parent ●Grand Parent ●Other Relative (Please Specify)
Family Data:
Relationship
First Name
Last Name
Date of Birth
Passport No.
Issued
Place
Valid Until
Spouse /
Partner2
Child
M
ChildF
ChildF
M
M
ChildF
M
3
Indicate
F type of valid visa
USA
Canada
Brazil
Schengen
UK
Other
EDUCATION INFORMATION (Graduation) :
2
4.
Strike out inapplicable item
3
Please consider period on board
STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: (Add separate sheet if data exceeds space available.)
Country of
Issue
Description of Cert / Course
Number
Date of Issue
(DD-MM-YY)
Date of Expiry
(DD-MM-YY)
Place of Issue
Issuing Authority / Body
(A)
Reg VI / 1 – Basic Safety Training
Personal Survival Techniques
Elementary First Aid
Fire Fighting & Fire Prevention
Personal Safety & Social Resp.
(B)
Reg VI / 2 –4 Additional Training
Proficiency in Survival Craft & Rescue
Boat
Fast Rescue Boats
Advanced Fire Fighting
Medical First Aid
Medical Care (Master / C/O)
(C)
Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag state endorsements)
Hong Kong Endorsement
4
4
4
4
4
Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you
(D)
Other mandatory/recommended Certificates / Courses – (as applicable)
ARPA (Reg II/1 + Solas)
Radar Observation
Bridge Team / Resource Mgmt.
Engine Team / Resource Mgmt.
ECDIS
Ship handling / Ship Manoeuvring
Shipboard Security Officer
Security Related Fam. Cert.
Security Related Fam. Cert.
Security Awareness Certificate
Hazmat
English Language
Established Date : 15.10.2012
Page No : 2/6
Rev. No : 6
Rev. Date : 30.04.2014
Document : Crew Manning
Issued By : Crew Manager
Title : Employment Application For Ship Personnel
Established Date : 15.10.2012
Page No : 3/6
Rev. No : 6
Rev. Date : 30.04.2014
Documation : IST-106
Approved
: General Manager
Part : 3
ISM Kod 6.0
Document : Crew Manning
Issued By : Crew Manager
Title : Employment Application For Ship Personnel
Description of Cert / Course
Country of
Issue
Number
Date of Issue
(DD-MM-YY)
Documation : IST-106
Approved
: General Manager
Part : 3
ISM Kod 6.0
Date of Expiry
(DD-MM-YY)
Place of Issue
Issuing Authority / Body
(E)
GMDSS Certificates (including flag state endorsements)
GMDSS (Main Issuing Authority)
GMDSS (Flag State)
GMDSS (Flag State)
Other Special Requirement
Level1:Asst
Level2:Inchar
ge
Heavy Lift Familiarization Course
(F)
Description
Country of
Issue
Date of Issue
(DD-MM-YY)
Number
Date of Expiry
(DD-MM-YY)
Place of Issue
Do you know how to handle cranes for heavy lift cargo ops?
If yes, please specify which Capacity, type & brand of cranes you have
operated.
Bank Details:
Other Details: (if any)
Bank Name
Address (City of Bank-Country of Bank)
Branch Name
Account Name
Account Number
IBAN Number (26 Digits)
Swift Code of Bank
Sort Code
5.
General
(A)
Have you ever been denied a foreign visa?
If yes, state which country and reason (if known)
Yes
No
(B) Have you been the subject of a court of enquiry or involved in a maritime accident?
If yes, please attach details
(C) Give details below of two recent employers who we may contact for references:
Reference 1
Name of Company
Name of person to contact
Address
Country
Telephone
Established Date : 15.10.2012
Page No : 4/6
Rev. No : 6
Rev. Date : 30.04.2014
Yes
Reference 2
No
Issuing
Authority / Body
6. Sea Experience: (Last 5 years; start the listing below with the most recent experience)
VESSEL
Company
Name of
Vessel
Date From
dd/mm/yy
Date To
dd/mm/yy
Rank
Flag
(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”
B/C
CON
CHM
CH3
DRG
DP
FSH
FSO
Bulk Carrier
Cellular Container
Chem Carrier IMO I-II
Chem Carrier IMO III
Dredgers
Dynamic Positioning
Fishing Vsl
FloatingStorageOffldg
FPSO
GCD
HLV
LSH
LIV
LNG
LOG
LPG
Type (1)
FloatgProdStorOffldg
General Cargo
Heavy Lift Vsl
Lash
Live Stock Carrier
LNG Carrier
Log/Timber
LPG Carrier
GRT
MLP
MSV
NVL
RIG
OSV
OBO
O/O
OTH
DWT
Main Engine (2)
Multi-purpose
Multiservice Vessel
Naval Ship
Offshore Oil Rig
Offshore Supply Vsl
Ore/Bulk/Oil Carrier
Ore/Oil Carrier
Other
PAS
RFG
R/R
PRR
SAL
SRV
SUL
TUG
Salary
YAT
TNB
TNC
TNP
TNS
TNV
Yacht
Tanker(Bitumen)
Tanker(Crude)
Tanker(Products)
Tanker(Storage)
Tanker(VLCC/ULCC)
BHP
Passenger Ship
Reefer Vessel
Ro/Ro Carrier
RoRo-Pax
Sailing Vsl
Survey Vessel
Self-Unloader
Tug
Telephone Number and Position of
the Person to Contact for
References
Reason for
sign-off
Document : Crew Manning
Issued By : Crew Manager
Title : Employment Application For Ship Personnel
Documation : IST-106
Approved
: General Manager
Part : 3
ISM Kod 6.0
7. Medical History:
All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed,
the Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured
benefits.
(A)
Have you ever signed off a ship due to medical reasons?
Yes
No
If yes, please provide following details (If space is insufficient, attach additional sheets) :
Name of vessel
Date of occurrence
Place of occurrence
Brief description of illness/injury/accident
(B) Have you undergone any operation in the past?
Yes
No
If yes, please provide following details:
Details of operation
Date
Period of disability
Present condition
(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
Details of illness / accident
Date
Therapy/Treatment
(D) Please give details of any health or disability problem
Details:
8.
I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by you and any of your direct or indirect parent or subsidiary or
associated or affiliated companies (“Istanbul Shipping”) and your or Istanbul Shipping’s’ principals of personal data about me (including where appropriate data concerning racial or
ethnic origin, religious beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and the
outcome of any proceedings relating thereto) for all purposes related to my application for employment on board vessels managed by Istanbul Shipping or vessels owned or operated by
third parties for whom Istanbul Shipping is engaged to provide crew. I understand that this data will be stored in your databases in relation to my actual or potential employment by or
through Istanbul Shipping. Further, I confirm that the above may involve the transfer of my personal data within Istanbul Shipping or to third parties worldwide.
Place:
Date:
FOR OFFICE USE:
Established Date : 15.10.2012
Page No : 6/6
Rev. No : 6
Rev. Date : 30.04.2014
Signature:.