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C 05 - Seafarer Employment Application Form ABDUL RAHMAN

This document contains a seafarer employment application form used by Icon Ship Management Sdn. Bhd. The 4-page form collects personal details, certification and qualifications, medical history, sea experience, and references from applicants. It requests information such as name, contact details, passport number, medical conditions, rank and dates of previous employment, held certifications and courses, and bank account information. Applicants must also declare that the information provided is true and sign the completed form.

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Soekhaidir Suripno
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487 views4 pages

C 05 - Seafarer Employment Application Form ABDUL RAHMAN

This document contains a seafarer employment application form used by Icon Ship Management Sdn. Bhd. The 4-page form collects personal details, certification and qualifications, medical history, sea experience, and references from applicants. It requests information such as name, contact details, passport number, medical conditions, rank and dates of previous employment, held certifications and courses, and bank account information. Applicants must also declare that the information provided is true and sign the completed form.

Uploaded by

Soekhaidir Suripno
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

ICON SHIP MANAGEMENT SDN. BHD.

CHECKLIST & FORM

CF NUMBER : C 05
CF TITLE : Seafarer Employment Application
Instruction :  Please fill up below columns before submit to Crew Management Department.

Post Applied For: Attach 1 copy of


recent photograph
Trainee/OS AB Bosun here

E/Cadet D/Cadet Medic (Non-returnable)

Electrician Oiler Cook


3/Engineer 2/Engineer C/Engineer
2/Officer C/Officer Master *(Please tick /)

A. PERSONAL PARTICULARS
Name in Full (In block letters and as shown in I/C or Correspondent Address:
Passport):

I/C No.:
Travel Document: Contact Details:
Passport No. : Tel No. (Home) :
Date of Issue : Mobile No. (HP) :
Date of Expiry : Email Address :

Date of Birth (DOB): Place of Birth (POB): Nationality:

Religion: Height: Weight:

EPF No: SOCSO No: Tax No:

Seaman Book No: Seaman Card No: Seaman Card Expiry Date:

Eye Colour: Hair Colour: Preferred Airport:

Coverall Size: Safety Shoe Size: Blood Type:

Smoking: Yes No Marital Status: Single Married Divorced Widowed

Family Details
Spouse Occupation Yes No
Name of Spouse:___________________________ Age: ______

Children Name: ____________________________ Age: ______ Sex: _______ DOB: ____________


Children Name: ____________________________ Age: ______ Sex: _______ DOB: ____________
Children Name: ____________________________ Age: ______ Sex: _______ DOB: ____________
Children Name: ____________________________ Age: ______ Sex: _______ DOB: ____________
Next of Kin Details

Full Name: _____________________________ Relationship: ________________________________


Address: _____________________________ Telephone No:________________________________
_____________________________

Uncontrolled when printed or copied Document custodian: GMFHC


Rev. 2.0 / 07 June 2018 Author: Head of ISM
Page 1 of 4 Approval by: Director
ICON SHIP MANAGEMENT SDN. BHD.
CHECKLIST & FORM
B. CERTIFICATE OF COMPETENCY
Type of Certificate of Competency Held :

Certificate No. : Issuing Authority : Date of Issue :

C. SEA EXPERIENCE (To be listed from top)


Company Vessel Type GRT BHP Rank Sign-On Sign-Off

D. MEDICAL HISTORY (It is utmost importance that all illness other than minor afflictions
should be stated. The Company is entitled to refuse any claim for treatment, cost or any
other insured benefits if a complete declaration of all previous illness has not been given)
1) Have you ever signed off a ship due to medical reasons?
If yes, please provide following details.
Brief Description of illness / injury / accident: Yes No

2) Have you undergone any medical operation in the past?


If yes, please provide details.
Brief Description of medical operation: Yes No

3) Any health or physical disability problem?


If yes, please provide details.
Brief Description: Yes No

4) Have you been seriously ill for the last 12 months?


If yes, please provide details.
Brief Description: Yes No

5) Do you have the following illness:


If yes, please tick the appropriate box.
Asthma Heart Yes No
Blood Pressure Diabetic
Gout

Uncontrolled when printed or copied Document custodian: GMFHC


Rev. 2.0 / 07 June 2018 Author: Head of ISM
Page 2 of 4 Approval by: Director
ICON SHIP MANAGEMENT SDN. BHD.
CHECKLIST & FORM

E. GENERAL
Willing to accept lower rank? Yes No
Ability to understand instructions in English (For Rating Only) Yes No
Adequate understanding of written and spoken English (For Officers / Engineers) Yes No
Willing to work outside Malaysia Yes No
Have you ever been denied a foreign visa? Yes No
If yes, please state country and reason (if known)

Have you ever been subject of a court enquiry or involved in maritime accident? Yes No
If yes, please state details:

Have you ever work for Company or Vessel having ISM / ISO Certifications?
If yes, please fill details below:
Company Vessel Position

F. REFERENCES (Please give referees from 2 recent employers who we may contact for reference )
Name of Company : ________________________________ Contact No. : ________________________
Name of Company : ________________________________ Contact No. : ________________________

G. BANK DETAILS

Bank’s Name :
Account No. :
Account Holder Name :
I/C No. :
Bank Branch :

H. OTHER CERTIFICATES HELD (To be filled by Crewing Executive / Overseas Manning Agencies)
COURSES/CERTIFICATES Verify Number Date of Issue Date of Expiry
Basic Safety Training (BST)
Proficiency in Survival Craft & Rescue Boat
Advanced Fire Fighting
Medical Care
st
Medical 1 Aid
Radar Navigation & Radar Plotting
ARPA Certificate
GMDDS General Operator Certificate (GOC)
Shipboard Management Course
ISO / ISM Course
Rating Watch Keeping Cert (Deck/Engine)
Basic Rigging and Slinging Course
Ship Security Officer Certificate (SSO)
Basic Offshore Safety Emergency
Training

Uncontrolled when printed or copied Document custodian: GMFHC


Rev. 2.0 / 07 June 2018 Author: Head of ISM
Page 3 of 4 Approval by: Director
ICON SHIP MANAGEMENT SDN. BHD.
CHECKLIST & FORM
Basic Food Handling Course
Loss Prevention System (LPS)
Basic Hydrogen Sulfate Course (H2S)

I hereby declare that the above is true.

Name : Date : Signature :

Uncontrolled when printed or copied Document custodian: GMFHC


Rev. 2.0 / 07 June 2018 Author: Head of ISM
Page 4 of 4 Approval by: Director

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