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LT Marine Application Template

This document appears to be a crew application for employment with LT Marine. It requests personal information such as name, contact details, availability, medical history, documents/certifications, and seagoing experience. The applicant must sign certifying the truth and completeness of the information provided, with the understanding that withholding or falsifying information could result in dismissal. The recruitment officer would receive the completed application.

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Eirvin James
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266 views4 pages

LT Marine Application Template

This document appears to be a crew application for employment with LT Marine. It requests personal information such as name, contact details, availability, medical history, documents/certifications, and seagoing experience. The applicant must sign certifying the truth and completeness of the information provided, with the understanding that withholding or falsifying information could result in dismissal. The recruitment officer would receive the completed application.

Uploaded by

Eirvin James
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

LT MARINE

Email: apply@lt-marine.com Phone: (0908) 867 4603


Landline: 8474 2031

CREW APPLICATION Date of application: __________________


Recruitment Officer: __________________
For the position: ______________________
Remarks: __________________________
Date of availability: ___________________

last name first name middle name

WhattsApp/viber
Salary/Expectation number Skype ID number

mobile number Desired Vessel email address

Address

provincial address (if different from above)

ag
date of birth (day/month/year) place of birth (town, city) e civil status

Religion height (ft, in) weight (lbs) PPE size (S, M, L, XL, or XXL) shoe size

name of wife or partner no. of children

address of partner (if different from above) contact numbers of partner

name of father name of mother

address of parents contact numbers of parents

SSS no. Phil Health no.

date of last medical examination remarks on last medical examination (fit or unfit to work)

name of medical clinic address / contact numbers of medical clinic

Declare by putting a check (/) if the below statements are correct or incorrect.
Correct Incorrect If answered correct, please elaborate further.
1. I have been dismissed by a previous
employer for misconduct and violation of company
rules and/or POEA regulations.
2. I have had a serious illness, injury, and/or
operation that have affected my work in the past.
3. I am physically challenged in vision or
perception, hearing, and/or other handicaps.
4. I have previously been convicted in a court
of law in the Philippines and/or any other country.
5. I cannot swim.
CREW APPLICATION page 2

Documents and Training Certificates

Seafarer’s Documents
date issued expiry date
Type document number
(day/month/year) (day/month/year)
_ SIRB

_ Passport

_ POEA Eregistration

_ Certificate Limitation /
License
_ Certificate of Competency

_ Certificate of Endorsement

_ GOC

_ Certificate of Competency
(Ratings)
II/4
II/5
III/4
III/5
VISA’s
TYPE OF VISA DATE OF ISSUE DATE OF EXPIRATION VISA NUMBER

FLAG STATE ENDORSEMENT


BOOKLET
FLAG STATE DATE OF ISSUE DATE OF EXPIRATION NUMBER

VACCINE CERTIFICATE
TYPE OF VACCINE 1st Dose 2nd Dose Lot Number

YELLOW FEVER
BOOKLET NUMBER DATE OF ISSUE DATE OF EXPIRATION
POLIO VACCINATION
BOOKLET NUMBER DATE OF ISSUE DATE OF EXPIRATION
date issued expiry date
Type document number
(day/month/year) (day/month/year)
_ BST

_ PSCRB

_ ATFF

_ MEFA

_ MECA

_ SSO

_ SDSD

_ BOSIET / HUET

_ Rigging and Slinging

_ H2S

(others)
_
_

_
CREW APPLICATION page 3

Seagoing Experiences

no. of cause of principa


signed on route agency l
name of vessel vessel type grt kw position months discharge
(day/month/year) (d

I hereby certify that the above information provided by me is true, complete, and to the best of my knowledge. I further understand that my
willful withholding of information or making of any false statements in the application, is itself sufficient grounds for dismissal from the company.

__________________________________________
signature of applicant over printed name

Date: _____________________ Received by: ________________________________________

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