Asm_application.docx

Application Form

OFC-007 (06-18)

Date of application: Click here to enter a date. Name of manning agent: General: Last name: Date of birth: Address: Country: Telephone: E-mail: Position applying for: Available from: Sea history: Vessel name Vessel type Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item.

Please upload picture here

First name: Place of birth: City: Nationality: Mobile: Skype ID:

Flag

Rank

DWT

Maker, model, BHP/KW

Indian

From (dd/mm/yyyy)

Until (dd/mm/yyyy)

Y/M/D

Company

Application Form

Documents: Document name: Passport: Seamans book: Others:

Country:

OFC-007 (06-18)

Number:

National license / endorsement: Country: Number: Highest rank on endorsement: Valid for chemical tankers: Valid for oil tankers:

Place of issue:

Place of issue:

Medical examination: Country:

Date of issue:

Vaccination Yellow Fever: Date of issue:

Expiry date:

Others: Weight: Height: Marital Status: Religion: Nearest international airport Nearest domestic airport

Date of issue:

Expiry date:

Date of issue:

Expiry date:

Date of issue:

Expiry date:

Choose an item. Choose an item.

Other Flag State licenses: Country: Number:

Maritime education: Grade:

Place of issue:

School:

Choose an item.

Expiry date:

Country:

Date (from – to):

Application Form

OFC-007 (06-18)

Certifcates: Date of issue:

Expiry date:

Basic safety training, or: Personal survival techniques Fire prevention and fire fighting Elementry First Aid Personal Safety / Social Responsibility Proficiency in survival craft / PSCRB Advanced fire fighting GMDSS Medical care on board Medical First aid Radar navigator Shiphandling (IMO model course 1.22) Bridge team and resource management Engine room resource management Ship Security Officer Designated Security Duties ECDIS (generic – IMO model course 1.27, 40 hrs.) ECDIS JRC type specific training ECDIS FURUNO type specific training ECDIS TOTEM type specific training Tanker familiarization Advanced chemical training Advanced oil training Ship Safety Officer Ships Cook training certificate Steward/Messman certificate Incident Investigation Chemical Simulator Risk Assessment Framo Pump Course Visa: Date of issue: US Visa (C1/D) Schengen visa Next of kin: Telephone: Address:

Relationship: Date of birth:

Next of kin: Telephone: Address:

Relationship: Date of birth:

Next of kin: Telephone: Address:

Relationship: Date of birth:

Expiry date:

Application Form

OFC-007 (06-18)

Tanker Information Sheet - (For applications of Deck Officers, Bosun, Pumpman and deck ratings) YES/NO

Year*

Rank**

Chemical Products Aromatics: Styrene

YES/NO

Toluene

YES/NO

Benzene

YES/NO

Xylene

YES/NO

Alcohols & Glykols

YES/NO

Methanol

YES/NO

Ethanol

YES/NO

Iso-propyl Alcohol (IPA)

YES/NO

Butyl /Isobutyl Alcohol

YES/NO

2-Ethylhexanol (Octanol)

YES/NO

Mono Ethylene Glycol (MEG)

YES/NO

Molasses

YES/NO

Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank

Acids: Phosphoric

YES/NO

Sulphiric

YES/NO

Acrylic

YES/NO

Acetic

YES/NO

Rank Rank Rank Rank

Paraffins: Slack Wax

YES/NO

Hexane

YES/NO

Cyclohexane

YES/NO

Rank Rank Rank

Vegoils: Such as Crude Palm Oil, Rapeseed Oil, Soyabean Oil, Sunflower Oil, etc.

Yes/No

Year*

Rank**

Chemical Products

YES/NO

*Year: enter year of latest experience

Rank

Perchlorethylene

YES/NO

Trichlorethylene

YES/NO

MDI/TDI

YES/NO

Ethylene/Methylene Dichloride

YES/NO

Styrene Monomer

YES/NO

MethylTert-Butyl Ether (MTBE)

YES/NO

Butyl Acetate

YES/NO

Acetone

YES/NO

Acrylonitrile

YES/NO

Caustic Soda

YES/NO

Chloroform

YES/NO

Phenols

YES/NO

Propylene Oxide

YES/NO

Vinyl Acetate Monomer (VAM)

YES/NO

Urea Ammonia Nitrate

YES/NO

Dowanol

YES/NO YES/NO

Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank Rank

Clean Petroleum Products (CPP): Gasoil /Diesel Oil

YES/NO

ULSD

YES/NO

Gasoline

YES/NO

Naphta

YES/NO

Fuel Oil

YES/NO

Luboils

YES/NO

Rank Rank Rank Rank Rank Rank

**Rank: enter highest rank of experience

Parcel Trade Exp. (max. no during single voyage): Cargo Pumps Experience YES/NO Deepwell: YES/NO Framo YES/NO Marflex (electrical driven) YES/NO Centrifugal YES/NO Screw YES/NO Steam Turbine Vetting Inspections (indicate which) CDI Inspection (indicate date of last inspection) OCIMF Inspection (indicate date of last inspection) USCG Inspection (indicate date of last inspection) Dry Dock Experience (indicate shipyard) Experience in Delivery of New Buildings Trading Area (indicate areas) Ice Navigation Experience (indicate areas) Ship-to-Ship Experience (indicate areas)

Tank’s Coating Type Experience Expoxy Zinc Silicate Marineline Stainless Steel Tank’s Passivation Experience Wall Wash Experience

YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

Application Form

OFC-007 (06-18)

Annex I – data consent Hereby, I _____________ passport number _______________ , give my consent that ASM Maritime INC. / ASM Shipping LTD will hold and share with 3rd parties personal information as I provided for operational purposes only which includes: flights, crew change formalities, immigration, port authorities and any other party supporting the vessel’s operation. The personal information includes the following: Name, address, birth date, birth place, bank account number, wage details, medical records, NOK, email, phone number, passport, STCW documents, national documents, visas, flight records, sea service and PPE size.

I declare that the information given by me is correct to the best of my knowledge and I consent to disclosure of my personal information under the terms of the General Data Protection Regulations. I am fully aware that my personal information will be used by the Employer for operational reasons only. Signature __________