give tax information below only if requested to do so

1. Nominee / Next of Kin  & Family Details                                                                                    

Select From : ●Spouse  ●Partner  ●Child  ●Parent  ●Grand Parent  ●Other Relative (Please Specify)

Family Data:

Strike out inapplicable item        Please consider period on board

1. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: -

(Add separate sheet if data exceeds space available.)

(A)       Reg I

(B)       Reg VI / 1 – Basic Safety Training

(C)       Reg  VI / 2 –4  Additional Training

(D)       Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate  (including flag state endorsements)

Enter here actual descriptiongiven in the Competency Certificate / Watchkeeping Certificate held by you

(E)       Other mandatory/recommended Certificates / Courses – (as applicable)

(F)       GMDSS Certificates  (including flag state endorsements)

(G)       Reg V / 1 – Special Requirement  for Tankers

(H)            V/2 and V/3 – Special requirement for Passenger / Ro-Ro Passenger Vessels

(I)             TYPE SPECIFIC ECDIS COURSES

5. Sea Experience : (Start the listing below with the most recent experience)

Use only the following abbreviations for vsl types:

Engineers to give make/model of engines, e.g. “MAN 14V52/55A” or “SULZER 5RTA58”

6.   Medical History:                                                                                                                

Sheet 4

Allprevious illnesses other than minor afflictions should be stated below or updated. If not previously disclosed, the Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured benefits.

(A)    Have you ever signed off a ship due to medical reasons?                 Yes  No

         If yes, please provide following details (If space is insufficient, attach additional sheets) :

(B)    Have you undergone any operation in the past?                                   Yes   No

         If yes, please provide following details:

(C)    For what illnesses or accidents have you consulted a doctor during the last 12 months?

(D)    Please give details of any health or disability problem

7.    Bank Details:                                                         Other Details: (if any)

8.    General

(A)    Have you ever been denied a foreign visa?     Yes  X No

         If yes, state which country and reason (if known)

(B)    Have you been the subject of a court of enquiry or involved in a maritime accident?   Yes  X No 

         If yes, please attach details

(C)    Give details below of two recent employers who we may contact for references:

I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organisation.

Place: …………..…  Date: …04/09/2019……………..