PERSONAL DATA DOCUMENTS STCW OTHER STCW OTHER CERT. / COURSES SEA EXP. MEDI. HISTORY GENERAL Company 1. PERSONAL DATA (NAME SHOULD BE AS APPEARING IN THE PASSPORT) FIRST NAME * LAST NAME * PHONE NUMBER * LAND PHONE NUMBER FAX NUMBER E-MAIL * NATIONALITY * DATE OF BIRTH * PLACE/CITY OF BIRTH * MARITAL STATUS * SINGLE MARRIED GENDER * MALE FEMALE RELIGION * Buddhist Hindu Muslim Roman Catholic Christian RANK APPLIED * DECK DEP. MASTER DECK DEP. CHIEF OFFICER DECK DEP. 2ND OFFICER DECK DEP. 3RD OFFICER DECK DEP. DECK CADET DECK DEP. BOSUN DECK DEP. ABLE SEAMAN DECK DEP. ORDINARY SEAMAN (OS) ENG DEP. CHIEF ENGINEER ENG DEP. 2ND ENGINEER ENG DEP. 3RD ENGINEER ENG DEP. 4TH ENGINEER ENG DEP. ENGINE CADET ENG DEP. MOTORMAN/OILER ENG DEP. WELDER FITTER ENG DEP. ELECTRICAL OFFICER CATERING DEP. CHIEF COOK CATERING DEP. 2ND COOK CATERING DEP. MESSBOY STEWARD WILLING TO ACCEPT LOVER RANK * YES NO AVAILABLE FROM (DATE) * PRIMARY/PERMANENT ADDRESS * CITY * COUNTRY * Sri Lanka IF YOU ARE ALREADY HAVING A RESUME, PLEASE UPLOAD IT BELOW, 2. PERSONAL ID/DOCUMENTS/VISA DOCUMENT TYPE 1 SEAMAN'S BOOK (NATIONAL) DOCUMENT TYPE 2 PASSPORT DOCUMENT TYPE 3 US VISA C1/D DOCUMENT TYPE 4 YELLOW FEVER DOCUMENT TYPE 5 NATIONAL ID 3. STCW - COMPLIANT CERTIFICATES/COURSES AND OTHER QUALIFICATIONS 3.1 Pre-Sea Training (Deck Rating/Engine Rating/Marine Skilled Craftsman) CERTIFICATE NO - 01 QUALIFICATION TRAINING INSTITUTE FROM TO CERTIFICATE NO - 02 QUALIFICATION TRAINING INSTITUTE FROM TO CERTIFICATE NO - 03 QUALIFICATION TRAINING INSTITUTE FROM TO 3.2 Certificate of Competency & Ratings Watch-Keeping Certificate * Enter actual description given in the Certificate of Competency / Watch keeping Certificate held by you. REG 11/1-4, 111/1-4 CERTIFICATE OF COMPETENCY (COC)/CERTIFICATE OF PROFICIENCY (COP) REG 11/1-4, 111/1-4 WATCH KEEPING CERTIFICATE REG 11/1-4, 111/1-4 6G/4G WELDING CERTIFICATE REG 11/1-4, 111/1-4 LLOYDS - WELDING CERTIFICATE REG 11/1-4, 111/1-4 MLC - COOK CERTIFICATE REG V/1 ENDORSEMENT - OIL REG V/1 ENDORSEMENT - CHEMICAL REG V/1 ENDORSEMENT - GAS REG V/1 ENDORSEMENT - OTHER REG V/1 SPECIAL TANKER SAFETY (OIL) PARA 2 REG V/1 SPECIAL TANKER SAFETY (CHEMICAL) PARA 2 REG V/1 SPECIAL TANKER SAFETY (GAS) PARA 2 REG V/1 SPECIAL TANKER SAFETY (OTHER) PARA 2 3.3 OTHER STCW CERTIFICATES REG 1 PERSONAL TRAINING RECORD REG 1/14 REG 1 MEDICAL FITNESS CERT REG 1/14 REG VI/1 PERSONAL SURVIVAL TECHNIQUES REG VI/1 ELEMENTARY FIRST AID REG VI/1 FIRE PREVENTION & FIRE FIGHTING REG VI/1 PERSONAL SAFETY & SOCIAL RESP. REG VI/1 PROFICIENCY IN MARITIME ENGLISH REG VI/1 SEAFARERS WITH DESIGNATED SECURITY DUTIES REG VI/2 PROFICIENCY IN SURVIVAL CRAFT & RESCUE BOATS REG VI/2 FAST RESCUE BOATS REG VI/2 ADVANCE FIRE FIGHTING REG VI/2 MEDICAL FIRST AID REG VI/2 MEDICAL CARE (MASTER/CO) 3.4 OTHER MANDATORY / RECOMMENDED CERTIFICATES / COURSES - (AS APPLICABLE) GMDSS (GOC/ROC) GMDSS (GOC/ROC) ECDIS ECDIS ARPA (REG 11/1 + SOLAS) ARPA (REG 11/1 + SOLAS) HAZMAT HAZMAT RADAR SIMULATOR RADAR SIMULATOR BRIDGE TEAM MANAGEMENT BRIDGE TEAM MANAGEMENT BRIDGE RESOURCE MANAGEMENT BRIDGE RESOURCE MANAGEMENT BRIDGE E-ROOM RESOURCE MANAGEMENT BRIDGE E-ROOM RESOURCE MANAGEMENT SHIPBOARD SECURITY OFFICER SHIPBOARD SECURITY OFFICER SHIP SECURITY AWARENESS SHIP SECURITY AWARENESS TANKER FAMILIARIZATION TANKER FAMILIARIZATION NAVIGATION WATCH KEEPING SIMULATOR-OPERATIONAL LEVEL (RADAR OBSERVATION & PLOTTING) NAVIGATION WATCH KEEPING SIMULATOR-OPERATIONAL LEVEL (RADAR OBSERVATION & PLOTTING) ELECTRONIC NAVIGATION SYSTEMS ELECTRONIC NAVIGATION SYSTEMS RADAR OBSERVATION AND PLOTTING RADAR OBSERVATION AND PLOTTING INTERNATIONAL SHIP AND PORT SECURITY CODE (ISPS) INTERNATIONAL SHIP AND PORT SECURITY CODE (ISPS) OTHER (ADD BELOW IF ANY OTHER COURSES) OTHER (ADD BELOW IF ANY OTHER COURSES) 4. SEA EXPERIENCE (Please enter at least last 5 years experience to the listing below with the most recent experience in the top most row) All Fields Are Mandatory. SEA EXPERIENCE - 01 SEA EXPERIENCE - 01 SEA EXPERIENCE - 02 SEA EXPERIENCE - 02 SEA EXPERIENCE - 03 SEA EXPERIENCE - 03 SEA EXPERIENCE - 04 SEA EXPERIENCE - 04 SEA EXPERIENCE - 05 SEA EXPERIENCE - 05 5. MEDICAL HISTORY All previous illnesses other that minor afflictions should be stated below or updated. If not previously disclosed, the Company is entitled to decline payment of medical costs for treatment or for any other insured benefits. BLOOD TYPE O- O+ A- A+ B- B+ AB- AB+ (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 supporting documents) (B) HAVE YOU UNDERGONE ANY SURGICAL OPERATIONS IN THE PAST? YES NO If yes, please provide following details (C) FOR WHAT ILLNESSES OR ACCIDENTS HAVE YOU CONSULTED A DOCTOR THE LAST 12 MONTHS? Details of illness/accident. DATE THERAPY / TREATMENT (D) PLEASE GIVE DETAILS OF ANY HEALTH OR DISABILITY PROBLEM FROM WHICH YOU PRESENTLY SUFFER Detail - 01 6. GENERAL DETAILS (A) HAVE YOU EVER BEEN DENIED A FOREIGN VISA? YES NO If yes, state which country and reason (if known) (B) HAVE YOU BEEN THE SUBJECT OF A COURT ENQUIRY OR INVOLVED IN A MARITIME ACCIDENT? YES NO If yes, please attach details I hereby certify that the information contained in this form is correct and I understand that the TGM client Company may terminate my services at any time if any of the above information is found to be false. I understand that a medical examination at my own cost is a condition precedent to selection for employment and I express my willingness to be so examined (if required) and to furnish the TGM client Company Doctor with full details of my previous medical history. DECLARATION TO BE SIGNED BY THE APPLICANT * I ACCEPT TERMS & CONDITIONS RESUME SUBMISSION DATE
