APPLICANT’S PHOTO (photo is a must ) less than 18 yrs not eligible APPLICATION FORM

SHIPOWNER (UNDER MLC 2006) Pacific International Lines ( PTE ) LTD 140 Cecil Street. #03-00 PIL Building Singapore 069540	SEAFARER RECRUITMENT & PLACEMENT SERVICE OFFICE PACIFIC MANNING AGENCY A division of PIL (INDIA) PRIVATE LIMITED 811, RAHEJA TOWERS,177 ANNA SALAI, CHENNAI 600 002 BOARD :+9144 6684 0600/4318 1172/4353 4399 EMAIL : pma@maa.pacificmanning.com
RPSL LICENCE NO : RPSL/CHN/031

SECTION I
Rank Applied
Date of Availability DD-MMM-YYYY
SECTION II	Personal Details
Last Name/Surname
First Name
Name as per passport
Date of Birth	Place of Birth:
Nationality
Marital / Civil Status	Single Married Divorced Separated
INDOS No(for Indians)
Permanent Address
Present Address (if different from permanent add)
Home Principal Airport
Contact Number ( Mobile )
Tel
Alternate Tel
Email	Skype ID:
Height (in cms)	Weight (in kgs)
Boiler Suit Size	Shoe Size
SECTION III	Travel Documents
Doc Number	Issue Date	Place of Issue	Expiry Date
Passport
Seaman Book
USA Visa C1/D
Aust MCV
Yellow Fever

SECTION IV	Pre-Sea Training / Apprenticeship Details
Name of Institute	From	To	Type of Degree/Certification Obtained
SECTION V	Certificate of Competency Held (valid)
Class / Grade	Issuing Country	Certificate No	Date Issued	Expiry Date
SECTION VI	Certificate of Endorsement Held (valid)
Class / Grade	Issuing Country	Certificate No	Date Issued	Expiry Date
SECTION VII	Courses Attended and Certificates Obtained
Name of Course/Certificate	Institute	Place	Issue Date	Certificate No.	Expiry Date
AFF
PSCRB
Med FAID / Medicare ( as applicable)
PSSR
ARPA
RANSO
GMDSS
HAZMAT
ECDIS
SHIP SECURITY OFFICER (SSO)
SHIP HANDLING SIMULATOR
ENGINE HANDLING SIMULATOR
SECTION VIII	Medical History
Yes	No
Have you ever signed off a ship due medical reason?
Have you undergone any medical operations in the past?
Have you consulted a doctor during the past 12 months for an illness / accident?
Do you have any health or disability problems now?
If answer to any of the above is YES then give further details below or on a separate sheet of paper

Name of Applicant:

Vessel Name	Company	Vessel Type	GRT	TEU(Contr)	Engine Make &Type (in full)	BHP	Rank	S/on Date	S/off Date	Remarks (For short tours)

Name of Applicant:

SECTION IX	GENERAL
Yes	No
Have you ever been the subject of a court of enquiry or involved in a maritime accident?
Have you ever had a professional licence suspended or revoked
If yes to any of the above then please give full details below or on a separate sheet of paper
Any other information you wish to add in support of your application
Family Data (Spouse & Children only)
Sr No	First Name	Relationship	Date of Birth
1
2
3
4
Minimum 2 references of fellow seafarers preferably sr. ranks presently sailing with other Company
Sr No	Name of Seafarer	Rank	Contact Details
1
2
3

Declaration :

I confirm that the validity of all above mentioned documents covers the contract duration + 3mnths.

I hereby certify that the information given in my application form including sea service details are true and complete to the best of my knowledge. I agree my understanding that if employed by PIL, any false or incomplete statement on this application and submitted document will lead to my dismissal from the employment without notice or pay-in-lieu.

Name of Applicant: ---------------------------------

Signed: _______________________ Date: __________

Note: - Please note that company does not charge any recruitment fees for providing employment or for any processing fees for on-boarding.