Ground Floor to Fifth Floor Northpoint Corporate Tower

7502 Bagtikan cor. Guijo Sts. San Antonio Village, 1203 Makati City
Tel. no. / Fax No.: +632 856-5338
Email: inquiry@seacrestmaritime.com * recruitment@seacrestmaritime.com * crew@seacrestmaritime.com
Website: www.seacrestmaritime.com

APPLICATION/CREW-DATA FORM
Date of Application:
Position Applied For:

PHOTO

Alternative Position:
*PLEASE ENSURE THAT ALL REQUIRED INFORMATION ARE FILLED OUT.

A. PERSONAL INFORMATION
Surname:

First Name:

Date of Birth:

Place of Birth:

Age:

Sex:

Weight (kg):

Eye color:

Religion:

Blood Type:

Height (cm):

Middle Name:

Permanent Address:

Female

Zipcode:

Telephone No.:

Mobile No.:

E-mail Address:

Contact Address:

Tel. No.:

SSS No.:
Civil Status:

Male

PhilHealth No.:

PAG-IBIG No.:

Spouses Name: (Last name, Given name, Middle Name)

Date Married:

No. of Children:

Tel./Mobile No.:

Occupation:

Fathers Name: (Last name, Given name, Middle Name)

TIN:

Spouses Maiden Name: (Last name, Given name, Middle Name)

Place of Birth:

Date of Birth:
PhilHealth No.:

Date of Birth:

Occupation:

Tel. No.:

Address:
Mothers Name:(Last name, Given name, Middle Name)

Mothers Maiden Name:(Last name, Given name, Middle

Date of Birth:

Name)

Address:

Occupation:

Tel. No.:

CHILDREN
Child1:

Place & Date of Birth:

Child3:

Place & Date of Birth:

Child2:

Place & Date of Birth

Child4:

Place & Date of Birth:

Date of Birth:

Relationship:

Next of Kin:
Address of Kin:

Tel. No.:

Allotee 1:

Relationship:

Date of Birth:

Address:

Place of Birth:
Contact No.:

Allotee 2:

Relationship:

Date of Birth:

Address:

Place of Birth:
Contact No.:

B. EDUCATION
Highest Educational Attainment:

Attendance Date:

Name of School/Institute:
CREWING 002

Rev. No.: 08

Date Issued: 16-APR-2015

Page 1 of 4

C. DOCUMENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Number

Date Issued

Expiry Date

Place of Issue

Philippine issued Passport

MARINA Seamans Book No. (SIRB)
Seamans Registration Certificate (SRC)
PRC License
PRC ID
NTC GMDSS License
NBI Clearance
Certificate of Competency (COC)
Certificate of Endorsement (COE)
Ships Catering Services (NC I)
Ships Catering Services (NC II)
Others

D. VISAS

1.
2.
3.
4.

Australian Visa:
US Visa C1D:
US Visa B1/OCS:
Schengen Visa:

5.

Norwegian Visa:

E. FLAG STATE ENDORSEMENT

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Antigua & Barbuda License

Bahamas License
Cyprus License
Danish License/ DRC
GOC for GMDSS License
Hongkong License
Liberia License
Malta License
Marshall Island License
MPA License
Panama License
St. Vincent and the Grenadines License
St. Kitts and Nevis License
Others (please specify)

F. STCW 2010 TRAINING COURSES

15. Advanced Training for Chemical Tanker Cargo
Operations (ATCT)
16. Advanced Training for Liquefied Gas Tanker Cargo
Operations (ATLGT)
17. Advanced Training for Oil Tanker Cargo Operations
(ATOC)
18. Basic Training (BT)
19. Basic Training for Liquefied Gas Tanker Cargo
Operations (BTLGT)
20. Basic Training for Oil and Chemical Tanker Cargo
Operations (BTOC)
21. Electronic Chart Display Information System
22. Refresher Training for Basic Training
23. Management Level for Deck Officers (MLC DECK)
24. Management Level for Engine Officers
(MLC ENGINE)
25. Ship Security Training and Seafarers with
Designated Security Duties
26. Ship Security Officer (SSO)
27. Updating PSSR Training

G. DECK CERTIFICATES
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.

Smoke Diving Course

Radar Observer Course (ROC)
Automatic Radar Plotting Aids (ARPA)
Radar Simulator Course (RSC)
SRROC
INMARSAT
IMDG/ HAZMAT
GMDSS
Bridge Resource Management (BRM) or (MRM)
Bridge Team Management (BTM)
Deck Watchkeeping
OTHERS

CREWING 002

Rev. No.: 08

Date Issued: 16-APR-2015

Page 2 of 4

H. ENGINE CERTIFICATES
40.
41.
42.
43.
44.

Engine Room Simulator Course (ERSC)

Auxiliary Machinery
Control Engineering
Hydraulics & Pneumatics
Engine Watchkeeping

I. CATERING CERTIFICATES
45.
46.
47.
48.
49.

Culinary & Catering Course

Catering Management
Messman Course
Food Handling
Food Hygiene

J. COMMON CERTIFICATES
50. Advanced Training in Fire Fighting
51. Basic Safety Course with PSSR

52. Consolidated MARPOL 73/78 Annex I-VI

53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.

General Tanker Familiarization

ISM Code Familiarization
ISPS Familiarization
Dangerous, Hazardous and Harmful Cargoes
Inert Gas System / Crude Oil Washing
Maritime Law
MARPOL I
MARPOL VI
Medical Care
Medical First Aid
Prevention of Alcohol and Drugs in the Maritime
Sectors

64. OTHERS (please specify)

K. OFFSHORE TRAINING CERTIFICATES
65. Basic Offshore Safety Induction and Emergency
Training
66. Tropical Basic Offshore Safety Induction and
Induction and Emergency Training
67. Tropical Further Offshore Emergency Training

68. Further Offshore Emergency Training

69. Helicopter Underwater Escape Training

70. OTHERS (please specify)

L. VACCINATION
Yellow Fever:
Others:

CREWING 002

Validity:
Validity:

Rev. No.: 08

Date Issued: 16-APR-2015

Page 3 of 4

M. Sea Experience: most recent experience on the top

Type
Name of Vessel
Rank
Gross Tonnage
1.

Engine Made
Horsepower

Flag
Year Built

Manning Agency

Signed on
(dd/mm/yy)

Signed off
(dd/mm/yy)

Total
Months

Remarks

3.
5.
7.
9.
11.
13.
15.
17.
19.
21.
23.

N. Uniforms

Size

Cover-All
Safety Shoes
White Polo

__________________________________
Signature of Applicant

Black Pants (Waist Line)

CREWING 002

I hereby testify that all information given by me are correct and true
and that all submitted documents are genuine and obtained legally;
and hereby undertake to abide faithfully to the Code of Discipline as per POEA Rules and Regulations (Rule VI).

Rev. No.: 08

Date Issued: 16-APR-2015

__________________________________
Assessor

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