Elite Shipmanagement

MPA FORM C.28

Seafarer's Employment Application Form cum Checklist Rank Applied For

Recommended By

NAME

Place of Birth

Date of Birth / Age *

Blood Group

Seafarer's Permanent Address

Relationship to seafarer

Date of Application

Nationality

Height

Weight

Body Mass Index

Overall Size

Safety Shoe Size

Sex

Religion

(PHOTO)

No. of Dependents

Marital Status

Alternative Next of Kin, Relationship and Address

Next of Kin, Relationship and Address

Tel. No.(HOME) Mobile Document

Number

Issued by

Date of Issue

Date of Expiry

Number

Issued by

Date of Issue

Date of Expiry

International Passport Seafarer's Passport VISA - USA

(Please circle : Type B / C1 / D)

Seaman's Discharge Book Medical Fitness Certificate ( as per STCW / FLAG STATE ) STCW95 & Flag State Doucments

STCW Regulation No.

Officers' Certificate of Competency - COC Electro Technical Officer ( S TCW 2010 )

A-III/6

Singapore Certificate or Endorsement - COE Panama Licence / Seaman's Discharge Book Malaysia Certificate of Recognition Malaysia Seaman's Identification STCW Endorsement for Officers STCW Watchkeeping Certificate for Ratings STCW Special Training (V/1. V/2) STCW Familiarisation Training STCW Personal Survival Techniques -PST

A-VI/1-1

STCW Fire Prevention and Fire Fighting - FPF

A-VI/1-2

STCW Elementary First Aid - EFA

A-VI/1-3

STCW Personal Safety & Social Resp.-PSSR

A-VI/1-4

STCW Prof in Survival Craft / lifeboat - PSCRB

A-VI/2

STCW Prof in Fast Rescue Boats - FRB STCW Advanced Fire Fighting - AFF

A-VI/3

STCW Medical First Aid - MFA

A-VI/4-2

STCW Medical care on board ( Ship Captain )

A-VI/4-1

GMDSS General Operator's Certificate GMDSS Restricted Operator's Certificate

A-IV/2 IV/2

Designated Security Duties ( STCW 2010 )

A-VI/6-2

Security Awareness ( STCW 2010 )

A-VI/6-1

ECDIS ( STCW 2010 ) Able Seafarer Certificate ( STCW 2010 ) Ship Security Officer - SSO

A-VI/5

Cook's Training Certificate ( MLC, 2006 ) Other Supplementary Certificates & / Or Qualifications Name of Maritime Academy graduated from

*

Age - NOT below 18 years old. Manning Agency to verify against valid ORIGINAL Passport.

On the last column, Manning Agency : please tick to confirm that the documents have been verified with the originals and initial in this row. ** Where not applicable, please delete.. Form: Apex/C.121 (Apr/2013) Rev.2

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tick

NAME : No

Type

INSTRUCTIONS:

Vessel Name

DWT / GRT / Engine Type / KW

Rank

MPA ELITE SHIP MANAGEMENT Ltd

*AGE :

RANK : From

To

Mos.

Manning Agency

Principal

- Seafarer's Employment Application Form Sign Off Reason

(1) Plese fill up the lastest service on top. (2) For Deck officers & ratings, indicate DWT/GRT. For Engine officers & ratings, indicate Engine Type/KW. (3) Please include all your services or the last 10 ships for those who has long experiences. You may use additional pages to show your earlier experiences.

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0.0 APPLICANT'S DECLARATION

Please answer the following questions Are you below 18 years old ?

Yes / No

If yes, please provide details. * The minimum age for any seafarer ( including ship’s cook ) to be employed, engaged or work on board Apex managed vessels shall be 18 years old and above.

Have you previous injuries or sickness ?

I certify that the information given by me herein are true and correct to the best of my

Premature termination of contract ?

knowledge. Any false information may be subjected to legal actions ( including dismissal ).

Have been dismissed or logged for mischief ? Have bee involved in industrial dispute ? Any criminal offence ? Have been refused entry by any country ? Any special diet or religious restrictions ? Any medical restrictions / drugs / allergies ? Any alcohol drinking habits ?

Signature of seafarer

Any past history medical / mental condition? Can we make reference check with ex employers ? FOR OFFICIAL USE ONLY Interview assesment

English

Poor

Ave. Good

Reference check done by / Date

Please provide details

Manning Agency's Interview report to describe seafarer's technical competence & experience

Previous employment /agent PIC ?

Speak/ Read

Verify service record

Write

Verify reason for leaving

Physical

Verify overall appraisal

Personality

Verify relationship / habits

Intelligence Attitude Co-Operations Motivation

Interviewer's Name / Date

Suitability

VERIFIED BY : Name : ____________________ Position :_____________ Signature:_______________ * Manning Agency to check AGE against valid ORIGINAL Passport and confirm the seafarer is NOT below 18 years old.

Learning ability

Type of ships

* Manning Agency to tick against the no. column to verify sea service against original sea service record book

Safety

Type of Trade / Principal

Proposed / Assiged to principal / Ship / Date

Last Drawn Wages VERIFIED BY : MPA Crewing Dept : Name ___________________ Signature __________________ * APEX Crewing Dept to check the AGE against COPY of the valid Passport and confirm seafarer is NOT below 18 years old.

Form: MPA /C.28 (Apr/2013) Rev.2

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