Personal Information
Position applied for
Ex-Crew?
Sex
Last Name
First Name
Middle Name
Date of Birth (mm/dd/yyy)
Place of Birth
Civil Status
Blood Type
No. of Dependents
Temporary Contact Address
Permanent Contact Address
Height (feet/inches)
Weight (lbs)
Eye Color
Complexion
Mother's Maiden Name
Distinguishing Marks
Religion
○Male ○Female
Education
School
Period (mm/dd/yyyy)
From
Certification/Diploma/Course
To
High School
Vocational School
College
Graduate School
Licences and Other Required Documents
Number
Rank
Date Issued
Expiry Date
(mm/dd/yyyy)
(mm/dd/yyyy)
Seaman's Book
U.S. Visa
Passport
Training Certificates
Course Name
Certificate Number
Date Issued
(mm/dd/yyyy)
Basic Safety Course
Personal Safety & Social Responsibility
Prof. in Survival Craft & Rescue Boat
Prof. in Fast Rescue Boat
Advanced Training in Firefighting
Medical Emergency - First Aid
Crowd Management - Ro-ro/Passenger Ship
Crisis Management - Ro-ro/Passenger Ship
Crowd Management - Passenger Ship
Crisis Management - Passenger Ship
Ship Simulator & Bridge Teamwork
Maritime English
Messman Course
Deck/Engine Watchkeeping
GMDSS (regular)
Crisis Management & Human Behavior
Extended Firefighting
HAZMAT
Human Relation & Development Course
MARPOL Annex I
Name of Training Center
MARPOL Annex II
Service Record
(Please arrange in chronological order starting from past to present service)
Manning Agency
Name of Vessel
Rank
Past Employment
Land Base Experience
Last Employer
Position
Address
Contact Person
Tel(s)
Shipboard Experience
Last Philippine Manning Agency Employer's
Name
Contact Person
Tel(s)
Name of Foreign Principal
Sign-On
Sign-Off
Total
(mm/dd/yyyy)
(mm/dd/yyyy)
Months
Vessel Type
GRT
Engine Make
BHP
Registry
Attended to vessel during:
Experienced incidents of:
Dry-dock
Grounding
New Construction
Towing another vessel
Major Conversion
Collision
Others:
Abandon Ship
Rescue
Fire
Smuggling
Major Oil Pollution
Others:
Beneficiary Information
Beneficiary 1:
Last Name
First Name
Middle Name
Address
Relationship
Gender
Birthday (mm/dd/yyyy)
Tel(s)
○Male ○Female
Beneficiary 2:
Last Name
First Name
Middle Name
Address
Relationship
Gender
Birthday (mm/dd/yyyy)
○Male ○Female
Tel(s)
Dependents Information
Dependent 1:
Last Name
First Name
Middle Name
Civil Status
Address
Relationship
Gender
Birthday (mm/dd/yyyy)
Birthplace
Tel(s)
If dependent is disabled,
please state disability and
date acquired
Dependent 2:
Last Name
First Name
Middle Name
Civil Status
○Male ○Female
Address
Relationship
Gender
○Male ○Female
Birthday (mm/dd/yyyy)
Birthplace
Tel(s)
If dependent is disabled,
please state disability and
date acquired
Dependent 3:
Last Name
First Name
Middle Name
Civil Status
Address
Relationship
Gender
Birthday (mm/dd/yyyy)
Birthplace
Tel(s)
If dependent is disabled,
please state disability and
date acquired
Medical History
Any previous surgery?
○No ○YES
Any previous illness?
○No ○YES
Any previous handicap?
○No ○YES
Any drug/alcohol problem?
○No ○YES
Please describe
briefly:
Please describe
briefly:
Please describe
briefly:
Please describe
briefly:
Attach CV / Résumé:
By submitting this online application, I hereby confirm that the information given by me is true and correct to
the best of my knowledge and belief. I have not withheld any information that may affect my application
unfavorably and any false data herin constitutes ground for disqualification oracceptancenon- of my application.
I understand that a strict medical examination inclusive of a Drug and Alcohol test is a company prerequisite for my
employment. I am willing to be examined and to provide this company's accredited medical clinic a complete and
detailed personal medical history. I agree that the findings and results of the examinations are final and if declared unfit,
I will pay all costs incurred by PTCI for and in relation to my proposed employment.
Lastly, I confirm that if my employment travel documents expire or become invalid during the course of my contract,
and are not renewable during this time for various reasons, my contract of employment stands subject to
cancellation. I further understand that if I have to be repatriated because of expire travel documents, all costs in
relation to this will be charged to my account.