Fillable Application/ Personal Data Form – No

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Application/ Personal Data Form – No

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Form: Y-OP-001 Rev: 3 Date: 11 MAR 2011
Application/Personal Data Form – No ________
Ex-crew Recommended by Ex-crew (Please state: ________________________________________________)
New Applicant Recommended by Others (Please state: __ ________________________________________________)
Last Salary (USD)
APPLICANT FOR
Date Applied
Log –in No.:
Rank applied for
Certificate of Competency Rank
Date available
Surname
First Name
Middle Name
Father’s name
Mother’s name
Citizenship / Age
Permanent Address
Date/Place of birth
Willing to accept lower rank? (Yes/No)
e-mail:
Telephone No.:
Spouse’s name
Number of Children
Mobile No:
Height (cm)
Weight (kgs)
Total Sea Service in Rank
Total Sea Service
Sea experience
Rank
VESSEL
FLAG
Type of
Vessel
G.R.T
Engine
type/model
B.H.P./
KW
NAME OF
PRINCIPAL
Manning Agent
FROM / TO
DDD/MMM/YYY
DURATION
Y / M / D
Reason of
Discharge
Seaman Book
No:
Issue Date:
Exp. Date:
USA Visa Exp. Date:
Passport
No:
Issue Date:
Exp. Date:
Cert Of Co mpetency
No:
Issue Date:
Exp. Date:
I hereby certify that t he statements made on this application form are true and correct. I understand that misinterpretation or omission of facts may result to the rejection of my application or my dismissal from the ship. I also certify that I have
not paid nor promised to pay any money or other considerations in exchange of my employment. I further confirm that I underst and, speak and write the English language.
Seaman’s signature over pri nted name: _________________________________________________
FO R MANNING O FFICE USE O NLY
Missing Training
Requirements (as per Client):
Remarks:
Assessed by
Date:
(Name & Signature)
Interviewed by
Date:
(Name & Signature)
Approved by
Date:
(Name & Signature)
Seaman
(Signature)
CONTRACT DURATION
SALARY
REJOINING BONUS
HIGHER LICENSE
Disclaimer: Yialos Manning Services Inc. will carry-out all the necessary background checks on the information provided by the applicant. Yialos Manning Services Inc. shall not be held liable for any loss or damage incurred as a
result of the willful act by the applicant to mislead or to include false information.
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Application Personal Data Form No

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Completed 8 February 2021

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