CREW MANUAL GENERAL FORM

Card No Crew-001A Version 1 2022-09-06

Subsidiaries Application form

APPLICATION FORM ATTACH

RECENT
PHOTO

Njordships Management India Pvt Ltd,Unit 101,Akshaya Shanta Door No: 27/44

Position applied for:

Type of vessel:
Availabibity date:

Are you responding to a media advertisement? YES/NO

If YES, please state which one

Are you applying upon personal or professional recommendation? YES/NO

If YES, please state who

Surname: First name:

Other names Known as Nationality:

Place of birth: Date of Birth: Age: Male Female

Passport
Date of
Number Place of issue issue Date of expiry Issuing Authority

Visas
Type Number Place of issue Date of issue Date of expiry
C1/D (USA)
C1 (USA)
D (USA)
Australia Entry visa
MCV (Australia)
Schengen

Education Background
School / College From To Highest qualification attained

Personal details
Full address:

Postal code: Country:

E-mail:

Home tel number:

Mobile phone:

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Domestic Airport International Airport

Marital status:

Full name of Next of Kin: Relationship

Address of Next of Kin if
different from above
Phone if
different from above

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Dependents
Name Date of birth Age Gender Relationship

Person to contact in case of emergency

Name: Relationship

Address:

Phone number: Mobile number:

National Seaman's Book

Date of
Number Place of issue issue Date of expiry Issuing Authority

National Certificate of Competency (COC)- Licences

Grade Issuing Authority Number Date of Date of expiry Place of Issue Date revalidated Date expiry
issue

National GMDSS & Endorsement

Issuing Authority Number Date of Date of expiry Place of Issue
issue

Medical Fitness Certificate

Type Date of issue Date of Expiry

Yellow Fever Vaccination

Date of Issue Date of Expiry

Foreign languages other than English

Level: Beginn
Language
er Intermediate Advanced

Medical History
Have you ever signed off from
a ship due to medical reasons? Yes / No If yes give details
Name of vessel Date of Occurrence

Brief description of Illness or Injury

Other personal details

Height: Weight: Colour of Hair:

Colour of eyes: Safety shoes size: Boiler suit size:

Uniform Shirt size: Uniform Trousers size:

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Details of other Marine courses

Type of Marine Course IMO model Reference- Regulation Number Date of issue Date of expiry
course
1.19 - 1.20 1.13 - STCW Reg.
Basic Training 1.21 A-VI/1-1 to A-VI/1-4

Personal Survival STCW Reg. A-VI/1-1

1.19
Techniques
STCW Reg A-VI/1-2

BASIC TRAINING
Basic Fire Fighting 1.20
STCW Reg A-VI/1-3
Elementary First Aid 1.13

Personal Safety & Social

STCW Reg A-VI/1-4
Responsibilities (Human 1.21
Relationship)

STCW Reg A-VI/2 par 1.3

Proficiency in survival craft & Rescue Boats 1.23
STCW Reg A-VI/3
Advanced Fire Fighting 2.03
STCW Reg A-VI/4-1
Medical First Aid 1.14
STCW Reg A-VI/4-2 par 2
Medical Care 1.15
STCW Reg II/2
ROP 1.08
STCW Reg II/1
ARPA / NCC 1.07

Radar Simulator
STCW Reg II/1 par.2.5
ECDIS 1.27
US 49 CFR 172.700-
HAZ MAT 172.204
STCW
Ship simulator bridge teamwork 1.22 Reg II/1

BTM / ETM
STCW Reg VI/5 / ISPS
Ship Security Officer (SSO) Code

BASSnet
STCW Reg II/1 & II/2
Ship handling & manoeuvring
STCW Reg VIII/2
Bridge resource management US33CFR 157.415

Loading software (name it)

Large Vessel Handling Simulator / Engine CMA CGM

Room Simulator

Indos Number

Upgradation Course

Revalidation Course for renewal of CoC

High Voltage Training

Reefer Training

Engine Maker’s Training

Crane Manufactures training

ISPS
Vessel security training course code
IMO Assembly Res
Ship Safety Officer A741(18)
UK MCA
ISF Marlins English test

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Flag State Documents
Document Grade Number Place of Issue Date of Issue Date Expiry

Malta:

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Employment history (at least the last 5 years)

Vessel * Company Manning Agent Trading area Vessel Flag DWT / Year Main Engine Position Sign on Sign off Total Reason
type TEU built date date mm/dd for
** leaving
Make Type KW
***

* or industry sector if ashore

** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off
*** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract
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Summary of Experiences (in number of years)
Years as/ Bulk
Container Tanker Roro others (Please state)
on carrier
Master -
C/E
C/O - 2/E

2/O - 3/E

3/O - 4/E

E/O

Total

Years as/ Sulzer Sulzer SEMT Steam

B&W MAN others
on RTA RND Pielstick Turbine
C/E

2/E

3/E

4/E

E/O

Total

References
Do you have any objection if we will contact your last employers for
Yes/No
reference?
If YES please specify why:
If NO please specify below:

Please give the name and address of your current or immediate past employer
Name of company
Name of person to
contact
Address

Tel number

Please list two contactable referees or past employers

Name of company
Name of person to
contact
Address

Tel number

Name of company
Name of person to
contact
Address

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Tel number

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Bank details
Bank
Sort code:
name:
Branch Swift name
name IBAN number:

Address:
Account
Account
name/
number:
Title

I hereby affirm that all the information provided by me in this application is true and correct to the best
of my knowledge and belief; further, that no Certificate of Competency or License issued to me has
ever been revoked or suspended. I also certify that my medical history contained abocve is true and
any false statement or undisclosed material information about past illness or injury will disqualify me
from any employment benefits and claims.

Date_____________
___ Signature_______________________

* The company may contact my previous employer for references.

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