Pass Fail

Recruitment
Initials
Ops. Dept. Intro to Principal

PERSONAL DATA/APPLICATION FORM

S
BSM Crew Service Centre Philippines, Inc.
Rank/Position Applied For: _____________________________

Last Name: First Name Middle Name

Home Address: Tel. No.

Passport Photo
Contact Address: Cell No.
Email add:
Place of Birth: Civil Status:

Wedding Date:
Course Finished: Year Attended Name of School:
From:(dd/mm/yy) To: (dd/mm/yy)

Interests/Activities/Hobbies:

Languages Spoken (pls. check all applicable For Office Staff Use Only:
choices):  IHTS Height: _______ Cm
 English Blood Pressure:_____________ Weight: _______ Kg
 Filipino
Religion: ___________________ BMI: _______
 Others_________________________
SSS No.: TIN No.: PAG-IBIG No.: PHILHEALTH No.:

Cholera Exp.: Yellow Fever Reference No.: Year Started Seagoing Years in Present Employment:
Employment:

Next of Kin
Name: Date of Birth (dd/mm/yyyy): Relationship:

Address: Telephone No.:

Children Below 21 Years Old

Name Sex Date of Birth (dd/mm/yy)

Total No. of Children:

Parents Details
Mother’s Maiden Name: Father’s Name:
Date of Birth: Date of Birth:
Home Address:

BSM/Ser 11/Effective 19.06.18/PDAF

 SEA-GOING EXPERIENCE
(most recent vessel first)

Previous Salary:

Salary Expectation:

Foreign Principal & Signed on Signed off No. of Type of DWT & Nat. of Nat. of
Local Agency Rank Vessel's Name & Flag Trade Route M.E. Make BHP or KW Cause of Discharge
Address (dd/mm/yy) (dd/mm/yy) Months Vessel GRT Master/Offs Ratings

BSM/Ser 08/Effective 21.01.13/PDAF 2 of 5

 CERTIFICATION AND OTHER DOCUMENTS
LICENSES AND DOCUMENTS
DATE ISSUED EXPIRY DATE LEVEL NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
CERTIFICATE OF COMPETENCY (OFFICERS)
CERTIFICATE OF ENDORSEMENT (OFFICERS)
CERTIFICATE OF PROFICIENCY (NWK / EWK)
CERTIFICATE OF PROFICIENCY (ABLE SEAFARER)
BOARD LICENSE
NC I - NC III
SEAMAN'S BOOK
PASSPORT
U.S. VISA
POEA E-Registration (ERN)
GOC
NATIONAL CERTIFICATIONS
DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
BASIC SAFETY COURSE
COP BT
ADVANCE SAFETY COURSE
CoP Advanced Training in Fire Fighting
CoP Proficiency in Survival Craft & Rescue Boat
CoP Medical Emergency - First Aid
CoP Medical Care
CoP Proficiency in Fast Rescue Boat
TANKER TRAINING CERTIFICATES
CoP Basic Training Oil/Chemical Tanker
CoP Basic Training Liquefied Gas Tanker
CoP Advanced Training in Oil Tanker
CoP Advanced Training in Chemical Tanker
CoP Advanced Training in Liquified Gas Tanker
NAVIGATIONAL
CoP Ship Security Officer
CoP SDSD / SAT
Safety Officer Course
ECDIS (Generic)
ECDIS (Specific)
BSM/Ser 09/Effective 19.06.18/PDAF 3 of 5
 CERTIFICATION AND OTHER DOCUMENTS
FLAG DOCUMENTS & CERTIFICATES
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
VESSEL FLAG: DATE ISSUED EXPIRY DATE GRADE NUMBER VERIFIED
(dd/mm/yy) (dd/mm/yy) (BSM use only)
SEAMAN'S BOOK
ENDORSEMENT / LICENSE
GOC / GMDSS ENDORSEMENT
OTHER CERTIFICATES:
1
2
3
BSM/Ser 08/Effective 27.05.19/PDAF 4 of 5
 S
BSM Crew Service Centre Philippines, Inc.
WORKING EXPERIENCE (pls. check all applicable)
 WATER TUBE BOILERS  HEAVY LIFT OPERATORS
 DUAL EVAPORATION BOILERS  COMPUTERS
 THERMAL OIL BOILERS  HYDRAULIC POWER PACKS
 MEDIUM SPEED ENGINES  SATELLITE TELEX
 SLOW SPEED ENGINES  RADIOTELEX
 ELECTRIC WELDING  ETHYLENE OPERATIONS
 GAS WELDING  DECK CRANES
 ELECTRONICS  OBO OPERATION
 AUTOMATION  INERT GAS SYSTEMS
 FRAMO PUMPS  REEFER CONTAINERS
 SUBMERSIBLE PUMPS  DERRICKS
 CRUDE OIL WASHING  TURBO GENERATORS
 BOW THRUSTER

Shore Employment Details

DATE
FROM TO Nature Of Employment Employers Name and Address

Working Gear Size

Collar (Cm): Chest (Cm): Waist (Cm):

Shoes (Cm): Winter Jacket: Rain Coat:

DECLARATION
I certify that the above information is true and accurate. No Certificate of Competence or License issued to me
has ever been revoked or suspended. Any false information would lead to denial of application.
I agree that during this application process I will be subjected to a computer based Professional and English
Language assessment test. The results of which is form part of this application.

I hereby confirm that I had no jail term and not admitted to a mental institution prior employment via BSM Crew
Service Centre Philippines, Inc.
I hereby confirm that I was never repatriated on medical grounds nor ever involved in an accident on board nor
ever required medical treatment following contract completion.
I hereby confirm that I had no past history of any serious medical condition which will affect my work ability at
sea.
I hereby confirm that I had not taken any disability compensation from any employer in the past due to a
condition which permanently affect my ability to work at sea.

Signature Date

BSM/Ser 12/Effective 19.06.18/PDAF 5 of 5