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)

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 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 for 6 mon ths Atta ch Photo copie s of title and all ente red pages

GENERAL & FURTHER EDUCATION

Dates
School & Colleges Attended Examinations Passed & Certificates Obtained
From To

DETAILS OF APPRENTICESHIP / CADETSHIP

Company: College Attended:

Date App/Cadet
Commenced: Country

Date App/Cadet
Completed: Final Attainment:

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 CERTIFICATE OF COMPETENCY / LICENCES HELD
Certificate / Country Certificate Date Place Issue Expiry
Grade
License of Issue Number Passed Issued Date Date
Competency
Flag Equivalent
Flag Equivalent

Attach Photocopies all pages

MANDATORY CERTIFICATES
(For Subjects already included in another certificate, enter N.A.)
Certificate Issued Place Issue Expiry
Course Undertaken/Endorsement
Number By Issued Date 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For Freshers & Ratings (Minimum for all seafarers, unless superceded by a higher grade)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
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.
†† Where req ui red for v es se l of lowe r to nnag e r es tric ted t rading onl y c ar ry in g this equ ip ment for long rang e C ommuni cati on.
* Mini mum required for all Ra ting s & Jun ior Officers no t holding Cer t/DC E belo w.
** Stri ke off whi ch not applicable , and indi cate detail s separa tel y if more than one .

ADDITIONAL QUALIFICATION
Certificate Issued Place Issue Expiry
Course Undertaken/Endorsement
Number By Issued Date Date
Efficient Deck Hand
Ship Board Safety Officer
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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

SPECIALISED EXPERIENCE TANKERS

VESSEL / SYSTEM / EQUIPMENT Months VESSEL / SYSTEM / EQUIPMENT Months
Multi-Grade Cargoes Remote Pumps / Valves
Ship to Ship Transfers Deck Cranes / Derricks
Closed Loading Steam Winches
Lube Oil Cargoes Hydraulic Winches
COW Systems Eductor System
Free Flow Systems Contrifugal Cargo Pumps
SBT Submerged Pumps
Cold / Hot Washing Double Hull Vessels
Auto Ullage Guages

SPECIALISED EXPERIENCE OTHERS / GENERAL

VESSEL / SYSTEM / EQUIPMENT Months VESSEL / SYSTEM / EQUIPMENT Months
GMDSS Instrument Air System
APRA Domestic Refrig system
Integrated Bridge Systems Dry Dock
Steam Turbines Air compressors
Water Tube Boilers Emergency Generators
Hydraulics Electronics
Machine Tool Operations Automation
Machine Assembly Fire Detection Systems
UMS Operation Switch Gear
Bridge Control System Computer Control
Controllable Pitch Propeler Pre-Planned Maintenance
Welding Gas / Electric Anchor Handling Tug
AC Power Plant Maintenance Boat
DC Power Plant 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:

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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:
New construction: Fire/Explosion:
Towed or Towing another vessel: Rescue/Man over board:
Grounding: Abandon Ship:

EXPERIENCE ASHORE
Designation From To Company Nature of duties G. Salary Reason for leaving

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 Date Expiry Small Pox Date Expiry
Yellow Fever Date Expiry Typhoid Date Expiry
Hepatitis 'A' Date Expiry

To the best of your knowledge, are you in every way medically fit for sea service? Yes No

The following photocopies of documents are also required: Confirm

1. Watchkeeping Certificates or Certificates of Service from previous ships. Yes No
2. References from previous employers. Yes No
3. Certificates from School/College/Nautical/Engineering/Trade Institutions. Yes No
Please mention alongside total number of photocopies attached.

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? Yes No
May we approach your PAST employers for a reference? Yes No
Have you ever had to leave a Company other than voluntarily? Yes No
Are you at present serving under Contract? Yes No
What period of notice does your present employers require?
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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: Account Number
Bank Sort Code:
Bank Name & Branch:
Bank Address

An special instructions required with remittance/payment

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 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 Standard Ocean Going Vessels Small Engines
GCO General Cargo CRT Crude Carrier CTR Container Ship SZR Sulzer CAT Caterpillar Tractor RUS Ruston Diesels
GCK GC with Stulcken Derrick PRT Product Carrier LSH Lash Ship MAN M.A.N. KVN Kelvin Diesels SKA Skandiaverken
CBI Combination Carrier LPG LPG Carrier VHC Vehicles Carrier BNW B.& W.-Burmeister & Wain GEM General Motors KOC Kockums
BLK Bulker LNG LNG Carrier ROR Roll on - Roll off MNB M.A.N. / B.& W. APH Alpha Diesel DAE Daewoo
ORC Ore Carrier CHT Chemical Carrier PSG Passenger Vessel DOX Doxford RNH Ruston & Hornsby YMZ Yamanishi Zosen
CEM Cement Carrier OBO Oil / Bulk / Ore FER Ferry GOT Gotaverken RRC Rolls Royce YMR Yanmar - Amagasaki
BTN Bitumen Carrier BKR Bunker Supplier FRO Ferry / Ro-Ro HNW Harland & Wolff DBZ Dailmer Benz DAI Daihatsu
SUL Self un-loader NHZ Non-hazardous REF Refrigerated Cargo PLK Pielstick DTZ Deutz HNK Hanshin Nainenk Kogyo
COL Collier LVC Livestock Carrier FIA Fiat LBN Lister Blackstone NIG Nigata
PSC Passenger-cum-Cargo TBC Timber Carrier MIR Mirrless Blackstone PAX Paxman Diesels TAK Takamatsu
STW Stork Werkspoor KRP Krupp MaK Machinenbrau KUB Kubota
Service Vessels AKA Akasaka Diesels BRN A.G. Bergens MAT Matsui Nigata
TUG Tug HOP Hopper LAN Landing Craft STT Steam Turbine WAR Wartsila / Nohab MAE Matsue
SAL Salvage Ship UTI Utility Vessel TRG Training Ship GST Gas Turbine
DRG Dredger SUP Supply Ship FSH Fishing Vessel TBE Turbo Electric
RES Research Vessel CAB Cable Laying Vessel FAC Factory Ship
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’ ‘c’
If combination of 2 types, write both abbreviations with hyphen in between For Controllable Pitch Propeller, abbreviations to be pre-fixed with

1 2 3 4 5 6 7 8 9 10
FROM TO RANK SHIP’S NAME COMPANY FLAG TYPE 1. DWT ENGINE 2. B-SHP/KW

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Use additional sheets, if required:

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For Official use only:

INTERVIEW CRITERIA & RECORD

NAME CDC NO. DATE RANK DATE

PRE INTERVIEW CHECKS

Yes No
1. Application form filled in and submitted

(a) The officer meets STCW requirements or short course FA I D AFF PS SSL GMDSS

Y N Y N Y N Y N Y N

2. Original of all certificates listed

On application form sighted. If any Yes No
missing then advise details of deficiency.

3 Travel documents valid until

4 Any restriction on Travel Document

5. If checked against circulation list of officers not suitable

for re-employment Yes No

PAST SERVICE RECORD / HISTORY

1. Reason for seeking employment with Terra-Marine

First Employment Promotional Reasons Higher Wages

Differences with previous employer Redundancy from previous employer

other, specify

2. If ever involved in

Collision Grounding Fire Abandonment

Yes No Yes No Yes 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
PageNo
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 [

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
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Than one person on interview panel)

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