Marine Officer CV Form (Rev 4.

1 - June 2011)
11/22/2012

CV No Remarks

Processed Date

Original copies of relevant certificates/records must be made available for verification and candidate briefed by contractor (with evidence) prior assessment otherwise candidate will be rejected.

Appointment for: SMR Assessment

Re-briefing

*Acceptance criteria for candidates with <2 years service in rank or promotion:
Shipboard/In-service competence assessment & recommendation by Master/ Chief Engineer, supported by DPA Practical mooring/vessel handling assessment by SMR/2x (for Workboat Master) Proof of at least 5 rig/barge moves done last 3 years (for AHTS/AHT Master) For contractor's input

Contractor Vessel Name Vessel Type Candidate Name Birth Date Nationality Position Certificate Of Competency Limitation Passport Number Seaman Book GMDSS Operator Certificate DP Operator Certificate Training Certification (STCW'95) * validity 5 years unless stated Personal Survival Techniques* Fire Prevention and Fire Fighting* Elementary First Aid* Personal Safety and Social Responsibilities* Proficiency In Survival Craft and Rescue Boats* Proficiency In Fast Rescue Boat* Advanced Fire Fighting* Medical First Aid and Medical Care Radar Navigation & Automatic Radar Plotting Aids* Shipboard Management*

Contract Holder Gross Tonnage Propulsion (KW) New In BSP Age < 2 Years In Rank* Promotion*
Date Format: MM/DD/YY

Regulation Expiry Date Expiry Date Expiry Date Expiry Date Issue Date

Issue Date Issue Date Issue Date Issue Date Issue Date Issue Date Issue Date Issue Date Issue Date Issue Date

Sea Service Records (Most recent first backdating to last 4 years) Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Vessel Vessel Type Period (MM/DD/YYYY) Duration From 0 Year Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Month Day From Month Day Rank GT To KW From Month Day Rank GT To KW From Month Day Rank GT To KW From Month Day Rank GT To KW From 3 Month 22 Day Rank GT To KW Month Day Rank GT To KW From Rank GT To KW

Date Format: MM/DD/YYYY

Accumulative Duration in Rank Proposed

0
Year Month Day

22

Sea Service Records (Most recent first backdating to last 4 years)-Continued Vessel Vessel Type Period (MM/DD/YYYY) Duration Year Vessel Vessel Type Period (MM/DD/YYYY) Duration From 0 Year Vessel Vessel Type Period (MM/DD/YYYY) Duration From 0 Year Vessel Vessel Type Period (MM/DD/YYYY) Duration From 0 Year Vessel Vessel Type Period (MM/DD/YYYY) Duration From 0 Year Vessel Vessel Type Period (MM/DD/YYYY) Duration From 0 Year 0 Month 0 Day 0 Month 0 Day Rank GT To KW 0 Month 0 Day Rank GT To KW 0 Month 0 Day Rank GT To KW 0 Month 0 Day Rank Master GT To KW Month Day Rank GT To KW From Rank GT To KW

Date Format: MM/DD/YYYY

Total Accumulative Duration in Rank Proposed

0
Year

0 Month

0 Day

Mandatory scanned copies (legible/readable) of following certificates/records to be attached with this form: 1) Certificate of Competency 2) CoC Endorsement 3) Seaman Discharge Book (pages showing personal particulars & last 4 year sea service) 4) International Passport (personal particulars page showing expiry date) 5) GMDSS Operator Certificate (if applicable) 6) DP Operator Certificate & Training Logbook (if applicable)