TERRA-MARINE
Form FP-1
File 118.1.1
QA-R:0/03-13
APPLICATION FORM
Dear Sirs,
I decleared that all documents are genuine and all information given are
correct to the best of my knowledge & belief.
Yours faithfully
Signature
Rank Applied For:
Availability Date:
Application Date:
Application Place:
First Name:
Other Names:
Religion:
Martial Status:
Nationality:
N.I.C. No.
Date of Birth:
Place of Birth:
Father’s Name:
Mother’s Name:
Wife Name:
Date Married:
Mailing Address:
Permanent Address:
Telephone/Fax/E-mail:
Telephone/Fax/E-mail:
Nearest Main Airport:
NEXT OF KIN / FAMILY
N.O.K. Name:
Relation:
N.I.C. No:
Telephone/Fax/E-mail:
Address:
No.
Children Name
Sex
Date of Birth
1.
2.
3.
4.
LANGUAGE INFORMATION
English:
Italian:
French:
Spanish
German:
Others:
(To fill with V=Very Good / G=Good / F=Fair / P=Poor / N=No)
Page 1
ETHNIC ORIGIN
African
Asian
Caribbean
Oriental
UK/Eire
Other European
Other (please spec)
TRAVELLING INFORMATION
Country
Number
Issue Date
Expiry Date
Issued At
Passport:
*
National Seaman Book:
Foreign Seaman Book:
US C-1 Visa
US D Visa
US B1 B2 Visa:
Other Visa:
* Passport should be valid f or 6 months
Attach Photocopies of title and all entered pages
GENERAL & FURTHER EDUCATION
Dates
From
School & Colleges Attended
To
Examinations Passed & Certificates Obtained
DETAILS OF APPRENTICESHIP / CADETSHIP
Company:
College Attended:
Date App/Cadet
Commenced:
Country
Date App/Cadet
Completed:
Final Attainment:
CERTIFICATE OF COMPETENCY / LICENCES HELD
Certificate /
License
Competency
Flag Equivalent
Flag Equivalent
Grade
Country
of Issue
Certificate
Number
Date
Passed
Place
Issued
Issue
Date
Expiry
Date
Attach Photocopies all pages
Page 2
MANDATORY CERTIFICATES
(For Subjects already included in another certificate, enter N.A.)
Certificate
Issued
Place
Issue
Number
By
Issued
Date
For Freshers & Ratings (Minimum for all seafarers, unless superceded by a higher grade)
Personal Survival Techniques
Fire Prevention and Fire Fighting
Elementary First Aid
Personal Safety and Social Responsibility
Course Undertaken/Endorsement
Expiry
Date
For All Officers
Survival Craft, Rescue Boats
Advanced Fire Fighting
Medical First Aid
For Masters & Chief Mates
Take Charge of Medical Care
For Watchkeeping Ratings
Cert (Rating) part of Navigational Watch OR
Service Cert (Rating) part of Navigation Watch
Cert (Rating) part of Engine Watch OR
Service Cert (Rating) part of Engine Watch
Ancillary Certificates for Deck Officers
G.M.D.S.S.
Radio Telephony Certificate
Radar Simulator
Electronic Navigation (Systems / Aids)
Navigation Control Course (NCC)
Automatic Radar Plotting Aids (ARPA)
†
††
*
FOR TANKERS
* Tanker Familiarization (PET/CHEM/GAS)
**
Advanced Tanker Safety (PET/CHEM/GAS) **
**
DCE (PET/CHEM/GAS)
† Optional till January 2002, unless required by Owners/Flag state.
†† W here required for vess el of lower tonnage res tric ted trading only carrying this equipment for long range Co mmunic ation.
*
**
Mini mu m re quired for all Ratings & Junior Officers not holding Cert/DCE below.
Strike off which not appl icable, and in dicate details separately if more than one.
ADDITIONAL QUALIFICATION
Course Undertaken/Endorsement
Certificate
Number
Issued
By
Place
Issued
Issue
Date
Expiry
Date
Efficient Deck Hand
Ship Board Safety Officer
Bridge Team / Resource Management
Electronics for Engineers
Programme Maintenance System (PMS)
ISM Course
Ship Manned Module Course
Engine Plant Simulator Course
Boiler Water Treatment
Instrumentation & Control
Vibration Monitoring
Dynamic Positioning
Gas Welding
Electric Welding
Marine Computer Application
Industrial Management Course
Ship Simulator & Bridge Team work
Maritime Law for Ships' Officers
Attach Photocopies all pages
Page 3
SPECIALISED EXPERIENCE TANKERS
VESSEL / SYSTEM / EQUIPMENT
Multi-Grade Cargoes
Ship to Ship Transfers
Closed Loading
Lube Oil Cargoes
COW Systems
Free Flow Systems
SBT
Cold / Hot Washing
Auto Ullage Guages
Months
VESSEL / SYSTEM / EQUIPMENT
Months
Remote Pumps / Valves
Deck Cranes / Derricks
Steam Winches
Hydraulic Winches
Eductor System
Contrifugal Cargo Pumps
Submerged Pumps
Double Hull Vessels
SPECIALISED EXPERIENCE OTHERS / GENERAL
VESSEL / SYSTEM / EQUIPMENT
Months
GMDSS
APRA
Integrated Bridge Systems
Steam Turbines
Water Tube Boilers
Hydraulics
Machine Tool Operations
Machine Assembly
UMS Operation
Bridge Control System
Controllable Pitch Propeler
Welding Gas / Electric
AC Power Plant
DC Power Plant
VESSEL / SYSTEM / EQUIPMENT
Months
Instrument Air System
Domestic Refrig system
Dry Dock
Air compressors
Emergency Generators
Electronics
Automation
Fire Detection Systems
Switch Gear
Computer Control
Pre-Planned Maintenance
Anchor Handling Tug
Maintenance Boat
Crew Boat
Brief summary of sea service for period preceding last five years:
Details of any additional qualifications/special courses/naval service etc.:
Details of any technical groups/associations or professional guilds to which you belong:
Summary of experience ashore: please give details:
What nationalities of crews have you sailed with?
Have you ever been attached to a vessel during:
Major conversion:
Fire/Explosion:
Rescue/Man over board:
Abandon Ship:
New construction:
Towed or Towing another vessel:
Grounding:
EXPERIENCE ASHORE
Designation
From
To
Company
Nature of duties
G. Salary
Reason for leaving
Page 4
Details of any additional qualifications/special courses/naval service etc:
MEDICAL INFORMATION
Company Medical Date:
Valid upto:
Port Health Medical Date:
Valid upto:
If ever failed company medical [Yes/No]:
Date:
Drug and Alcohol Test at:
Date:
Date of last medical examination:
VACCINATIONS
Cholera
Yellow Fever
Hepatitis 'A'
Date
Date
Date
Expiry
Expiry
Expiry
Small Pox
Typhoid
Date
Date
Expiry
Expiry
To the best of your knowledge, are you in every way medically fit for sea service?
Yes
The following photocopies of documents are also required:
Confirm
1.
2.
3.
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Watchkeeping Certificates or Certificates of Service from previous ships.
References from previous employers.
Certificates from School/College/Nautical/Engineering/Trade Institutions.
Please mention alongside total number of photocopies attached.
No
Any other useful and relevant information you wish to add about yourself and career:
REFERENCES / AVAILIBILITY
May we approach your PRESENT employer for a reference?
May we approach your PAST employers for a reference?
Have you ever had to leave a Company other than voluntarily?
Are you at present serving under Contract?
What period of notice does your present employers require?
What notice do you require to attend an interview?
What date are you available for sea service?
REASONS FOR APPLICATION
State why you wish to leave your
present employment.
UNION MEMBERSHIP
Name of Union / Association
Membership Number
Position Held
Affiliation with Other Trade Organisations
BANK DETAILS (For allotments, other payments)
Account Name:
Bank Sort Code:
Bank Name & Branch:
Bank Address
Account Number
An special instructions required with remittance/payment
Page 5
RECORD OF SEA SERVICE (LAST 5 YEARS)
1. Abbreviations to use for Type Vessel
2. Abbreviations to use for Type Main Engines
Dry Cargo Vessels
Tankers
Specialized Vessels
GCO
GCK
General Cargo
GC with Stulcken Derrick
CRT
PRT
Crude Carrier
Product Carrier
CTR
LSH
Container Ship
Lash Ship
SZR
MAN
Sulzer
M.A.N.
CAT
KVN
Caterpillar Tractor
Kelvin Diesels
RUS
SKA
Ruston Diesels
Skandiaverken
CBI
BLK
ORC
CEM
Combination Carrier
Bulker
Ore Carrier
Cement Carrier
LPG
LNG
CHT
OBO
LPG Carrier
LNG Carrier
Chemical Carrier
Oil / Bulk / Ore
VHC
ROR
PSG
FER
Vehicles Carrier
Roll on - Roll off
Passenger Vessel
Ferry
BNW
MNB
DOX
GOT
B.& W.-Burmeister & Wain
M.A.N. / B.& W.
Doxford
Gotaverken
GEM
APH
RNH
RRC
General Motors
Alpha Diesel
Ruston & Hornsby
Rolls Royce
KOC
DAE
YMZ
YMR
Kockums
Daewoo
Yamanishi Zosen
Yanmar - Amagasaki
BTN
SUL
COL
PSC
Bitumen Carrier
Self un-loader
Collier
Passenger-cum-Cargo
BKR
NHZ
Bunker Supplier
Non-hazardous
FRO
REF
LVC
TBC
Ferry / Ro-Ro
Refrigerated Cargo
Livestock Carrier
Timber Carrier
HNW
PLK
FIA
MIR
STW
AKA
STT
GST
Harland & Wolff
Pielstick
Fiat
Mirrless Blackstone
Stork Werkspoor
Akasaka Diesels
Steam Turbine
Gas Turbine
DBZ
DTZ
LBN
PAX
KRP
BRN
WAR
Dailmer Benz
Deutz
Lister Blackstone
Paxman Diesels
Krupp MaK Machinenbrau
A.G. Bergens
Wartsila / Nohab
DAI
HNK
NIG
TAK
KUB
MAT
MAE
Daihatsu
Hanshin Nainenk Kogyo
Nigata
Takamatsu
Kubota
Matsui Nigata
Matsue
TBE
Turbo Electric
Service Vessels
TUG
SAL
Tug
Salvage Ship
HOP
UTI
Hopper
Utility Vessel
LAN
TRG
Landing Craft
Training Ship
DRG
RES
Dredger
Research Vessel
SUP
CAB
Supply Ship
Cable Laying Vessel
FSH
FAC
Fishing Vessel
Factory Ship
Standard Ocean Going Vessels
Small Engines
Other Type not listed to specify
*
Other Type not listed to specify
For UMS engines vessel, abbreviations to be pre-fixed with an asterisk
‘c’
If combination of 2 types, write both abbreviations with hyphen in between
1
FROM
2
TO
3
RANK
4
SHIP’S NAME
5
COMPANY
For Controllable Pitch Propeller, abbreviations to be pre-fixed with
6
FLAG
7
TYPE 1.
8
DWT
9
ENGINE 2.
‘c’
10
B-SHP/KW
Use additional sheets, if required:
Page 6
For Official use only:
INTERVIEW CRITERIA & RECORD
NAME
CDC NO.
DATE
RANK
DATE
PRE INTERVIEW CHECKS
1. Application form filled in and submitted
Yes
FAID
(a) The officer meets STCW requirements or short course
Y
N
AFF
Y
N
2. Original of all certificates listed
On application form sighted. If any
missing then advise details of deficiency.
PS
Y
No
SSL
N
Y
N
GMDSS
Y
Yes
No
Yes
No
3 Travel documents valid until
4 Any restriction on Travel Document
5. If checked against circulation list of officers not suitable
for re-employment
PAST SERVICE RECORD / HISTORY
1. Reason for seeking employment with Terra-Marine
First Employment
Promotional Reasons
Differences with previous employer
Higher Wages
Redundancy from previous employer
other, specify
2. If ever involved in
Collision
Grounding
Yes
Yes
No
No
Fire
Yes
Abandonment
No
Yes
No
If yes, details
3. If ever deported from any country
If yes, why
4. If ever criminally prosecuted
If yes, details
5. If ever signed of on medical grounds
no
once
1-3 times
More than 3 times
approx. total no. of days incapacitated
6. Any objection to references from previous employers
Yes
No
[
Page 7
N
INTERVIEW
1.
Appearance and general demeanour :
2.
Personality
3.
Communication skill
4.
Attitude to profession as judged by Interview
5.
Knowledge of duties and responsibilities of the rank applied for
6.
Assessment of professional knowledge as assessed by Interviewer:
Yes
No
ASSESSMENT
1.
Officer deemed fit for employment
2.
In what rank
3.
Suitable for assignment to types of vessels
(based on previous service and qualification)
4.
Suitable assignment on vessels with types of main engines
(for engineers on) (based on previous experience)
5.
Reference sought from:
1.
Mr.
of
2.
Mr.
of
3.
Mr.
of
Date of approval from principals to employ:
Officer Offered Employment as
on
Signed
(To be signed by each interview, if more
Than one person on interview panel)
Page 8