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APPLICATION FORM
1 Position
Position applied for: DECKBOY
Are you willing to accept any other positions? If YES, which positions would you consider? DECK CADET
Readiness from
2 Personal details
Name: Last Name (as per passport) ANORE First Name (as per passport) MARK LORENZ
Nationality: FILIPINO
Permanent Address: 439B C. BOLADO AVE. TATALA BINANGONAN RIZAL
Post code: No.: (Country) (Area) (Number)
Mobile No.:09292634321 (Country) (Area) E-Mail Id:
[email protected] (Number)
3 Education Background
Name From Year To Year Highest Qualification Attained
School
College PHILSIN COLLEGE GOUNDATION 2019 2022
INC
Pre-Sea Training
Other Qualifications
4 Identity documents
DOCUMENT COUNTRY NUMBER ISSUED PLACE EXPIRY (dd/mm/yyyy)
Passport: PHILIPPINES P1289082C 08-12-2022 MANILA 08-11-2032
Seaman’s book: National
Bahamian
Liberian
Panamanian
Other - Norway
5 National Certificate of Competency / Certificate of Proficiency (highest certificate held)
Class/Grade Issuing Country Certificate No. Date Issued Place Issued Valid Until
GMDSS
Other (IGF CoP)
5a National TANKER Endorsements (Management / Operation / Support)
Endorsement Type Certificate No. Date Issued Place Issued Valid Until
Petroleum
Liquefied Gas
Chemicals
6 Flag State Certificates of Endorsement (Issued by countries such as Panama, Liberia, Bahamas, etc)
Class Issuing Country Certificate No. Date Issued Place Issued Valid Until
1 WSM GLOBAL/MA/101 Rev 2 Dated 15/Apr/2020
6a Flag State Equivalent TANKER Endorsements (Issued by countries such as Panama, Liberia, Bahamas, etc)
Country/Type Certificate No. Date Issued Place Issued Valid Until
7 Courses Attended
Course Institution Place Date Cert. No.
Basic Fire Fighting EXACT
Advance Fire Fighting EXACT
Elementary First Aid EXACT
Medical First Aid EXACT
Medical Care
Personal Survival Techniques
Proficiency in Survival Craft - PSCRB
Personal Safety & Social Responsibility
Security Awareness Training for Seafarers
with Designated Security Duties
Ship Security Officer
Ship Safety Officer Course
Gas Carrier Familiarization
Advance Gas Carrier Course
Oil Tanker Familiarization
Advance Oil Tanker Course
Chemical Tanker Familiarization
Advance Chemical Tanker Course
Bridge Team Management
BRM / VRM / BERM / ERM
Ship Handling Simulator
Ships' Catering Services (Messman)
Certification for Cook (MLC 2006)
ECDIS - generic
ECDIS - type specific
High Voltage
Basic IGF course
Advanced IGF course
Other (please specify)
2 WSM GLOBAL/MA/101 Rev 2 Dated 15/Apr/2020
VESSEL NAME COMPANY# VESSEL TYPE FLAG DWT GRT MAIN ENGINE## B.H.P. RANK SIGN-ON SIGN-OFF SEATIME
/ YEAR BUILT DATE DATE
Make Type DD/MM/YYYY DD/MM/YYYY Y-M-D
#
Please ensure that the full name and address of your immediate past employer is entered in Section 9 ##
Required for engineer applicants only
3 WSM GLOBAL/MA/101 Rev 2 Dated 15/Apr/2020
9 References (Please give the name and address of your current or immediate past employer)
Name of company
Name of person to contact
Address
Post Code: Post Code:
No. (Country) (Area) (Number) (Country) (Area) (Number)
9a References (Please list two contactable referees or past employers in addition to Section 9)
Name of company
Name of person to contact
Address
Post Code: Post Code:
No. (Country) (Area) (Number) (Country) (Area) (Number)
10 Automatic review
If immediate employment is not available, do you wish to be considered for future vacancies?
If YES, please give any alternative contact details not shown in Section 2
11 Declaration
I hereby confirm that to the best of my knowledge, I have no restrictions of medical and/or criminal
nature that would prevent me from accepting a job offered following this application. X YES ☐ NO
I hereby declare that the above particulars are true and authorise you to contact the referees listed
above.
X YES ☐ NO
Date: (dd/mm/yyyy)
Name/Signature
4 WSM GLOBAL/MA/101 Rev 2 Dated 15/Apr/2020
