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Smms Application Form

This document is an application for employment as a Chief Officer. It requests basic personal information such as name, date of birth, address, education and training details. It also asks for sea service history, medical details, and an attached document checklist of required licenses and certifications. The purpose is to collect all necessary information to evaluate the applicant for employment as a ship's Chief Officer.

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Soyel Fernandes
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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49 views8 pages

Smms Application Form

This document is an application for employment as a Chief Officer. It requests basic personal information such as name, date of birth, address, education and training details. It also asks for sea service history, medical details, and an attached document checklist of required licenses and certifications. The purpose is to collect all necessary information to evaluate the applicant for employment as a ship's Chief Officer.

Uploaded by

Soyel Fernandes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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Template Version :- 1.

04 Revision :- 2

APPLICATION FOR EMPLOYMENT

Note: Fields with * sign are required fields in SMMS and should not be left blank.
Gender* Male
Crew Type* On Contract Crew Status* Available Rank* Chief Officer
Surname Date Of Birth
First Name* Height
Middle Name Weight

Home Address Other Addr

Address Address

Phone 1 Phone 2 Phone 1 Phone 2


Place of Birth Religion Cloth Size (EU) Cloth Size (
Marital Status Nationality Shoe Size
E-Mail
Basic Education Maritime Educ
Institute From Date To Date Particulars Institute* From Date To Date

Bank Detail
Bank Name Branch Beneficiary Name A/c Type

City Country State Zip Code Routing

Next Of Kin's Detail


Relation* Name* Date of Birth Address Relation* Name* Date of B

Sea Service
Note: Sequence for entering sea service records: Latest service should be entered at row no. 1 and then older services downward.
Vessel Name* From Date* Ship Type GRT Manager
No Period (Y/M/D) Rank
Flag To Date Engine Type BHP Manning Compan

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Has the applicant has ever signed off from a vessel on Medical Grounds. If yes, please furnish details.

Name of Vessel Date signed off Reason / Brief Description of Illnes

Have you visited the doctor in the last 12 months for any surgery / Illness. If yes, please furnish details

Date of Illness / Surgery Details of Illness and Treatment received


hief Officer
###
Photo
CM
KG

Other Address

Phone 2 ###
Cloth Size (US) ###

itime Education
To Date Particulars* ###

###

A/c Type A/c No.

Date of Birth Address

###

###
rd.
anager Sign Off Reason Cargo Crane
ng Company Remarks
`
on of Illness / Injury / Accident
DOCUMENT CHECK LIST
Guidelines for filling data
1. If any data entered against Training then that record will be saved in SMMS.
2. Country is required to save License record in SMMS.
Documents Clinic Name Issue
VACCINATION 1
VACCINATION 2
MEDICAL CHECKUP 1
MEDICAL CHECKUP 2
Documents Number* Issue
NATIONAL SEAMAN BOOK/ Seaman's Discharge Book (SDB) / Continuous Discharge Cert (CDC)
Seaman Book (Other)
INDOS
Seafarers Identification and Record Book (SIRB)
FLAG STATE SEAMAN BOOK (I.D BOOK)
PASSPORT
VISA - USA
VISA - Shengen
VISA - MCV
VISA - Other
Licenses Number Issue
Cert Of Competency - National
Cert Of Competency - Other
Cert of Endorsement - Panama
Cert of Endorsement - Singapore
GMDSS COC - National
GMDSS COC - Other
GMDSS COE - Panama
GMDSS COE - Singapore
ST

Expiry Remarks

Expiry Remarks

Expiry Remarks

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