CREW INFORMATION SHEET

Crew: Ex     New * Application Position:     * E-mail Address:     Application Date 27-May-2022
I. PERSONAL DATA
* Name:
* City Address: * Tel. No.:
* Provincial Address: * Cell. No.:
* Birthdate: Age: * Birthplace:
* Civil Status: * Religion:
Height (ft/in):
* Height (cm):
Weight (lbs):
* Weight (kgs):
* Father's Name: * Mother's Name:
Address:
Spouse Name: Birthday: Address:
Allottee's Name: Relation:
Bank Account: Branch:
Children's Name:
1. Sex: Birthdate:
2. Sex: Birthdate:
3. Sex: Birthdate:
4. Sex: Birthdate:
* Next of Kin Name: * Relation:
Seaman's Book No. Date Issued: Expiration:
Philippine License: License No.: Date Issued:
COC No.: Date Issued: Expiration:
Passport No.: Date Issued: Expiration:
POEA e-Reg No.: Position: Date Issued:
Yellow Card No.: Date Issued: Place Issued:
II. EDUCATION
Level School Attended Years Attended (From/To)
* College (Tertiary)
Degree (i.e Amt/Ame/Etc.)
III. CERTIFICATES & TRAINING
Course Training School Cert. No. Date Issued Authenticated Action
PRC TESDA
IV. USA VISA
DATE ISSUED VALIDITY VISA NUMBER
V. RECOMMENDED BY
NAME RELATION TELEPHONE
VI. SEA SERVICE (START WITH LATEST)
Vessel Name Vessel Type GRT/TEU Engine TYPE FLAG PHILIPPINE AGENCY FOREIGN PRINCIPAL/OPERATOR RANK DATE SERVICE DURATION CAUSE OF DISCHARGE ACTION
Sign On Sign Off Months Days


Yes No
1. * Are you willing to accept assignment in any part of the world?
2. * Are you willing to obey all terms and condition of employment?
3. * Are you a member of any Organization/Association (if yes, please specify which)
4. * Have you ever contacted any desease? If yes, specify nature?
5. * Do you have a case with POEA, PCG & other related Agency (If yes, state your case)