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Keyman Form – Sea Based

Personal Data
Family Data
Children
Child
Siblings Birth Order
Eldest to Youngest - including yourself
Sibling
Educational Background
Elementary
Secondary
Collegiate
Graduate
Vocational
Other
Medical History
Indicate Medical History in the space provided below, type NONE if not applicable:
Please answer YES or NO:
Licenses and Documents
Seafarer's Registration Number (SRN)
Seaman's Identification Record Book (SIRB)
PRC/Marina Board Certificate
Basic Training (BT) COP
Proficiency in Fast Rescue Boat (PFRB) COP
Proficiency in Survival Craft & Rescue Boat (PSCRB) COP
Medical Care (MECA) COP
Medical First Aid (MEFA) COP
Advance Training in Fire Fighting (ATFF) COP
Ship Security Officer (SSO) COP
Seafarer with Designated Security Duties (SDSD) COP
Global Maritime Distress & Safety System (GMDSS) COP
Ship Simulator and Bridge Teamwork (SSBT)
Yellow Card (For Cook)
Deck / Engine Watch
Deck / Engine Watch
Medical Certificate (Marina Accredited Clinic)
COC / D-COC Reg. No.
Work Experience
Begin with the most recent employment
Employment
Character References
Immediate Head/s and or HR Manager/s of previous companies
Reference
Other Information
Certification and Waiver
I hereby certify that the above information are true and correct. Any misinformation, misrepresentation or non-disclosure of facts would be sufficient cause for the termination of my services with the company.
 
Date
Personal Data
First Name Middle Name Last Name Nickname
First Name Middle Name Last Name Nickname
Present Address Present Address Civil Status Civil Status
Provincial Address Provincial Address Citizenship Citizenship
Email Address Email Address Religion Religion
Mobile Number Mobile Number Blood Type Blood Type
Place of Birth Place of Birth Height Height
Date of Birth Date of Birth Weight Weight
Family Data
Name of Spouse Name of Spouse Occupation Occupation
Home Address Home Address Company Company
Place of Birth Place of Birth Company Address Company Address
Date of Birth Date of Birth Office Tel. No. Office Tel. No.
CHILDREN
Name Birthdate Age Place of Birth Occupation Company
           
           
           
Name of Father Name of Father Name of Mother Name of Mother
Home Address Home Address Home Address Home Address
Place of Birth Place of Birth Place of Birth Place of Birth
Date of Birth Date of Birth Date of Birth Date of Birth
Occupation Occupation Occupation Occupation
Company Company Company Company
Company Address Company Address Company Address Company Address
Office Tel. No. Office Tel. No. Office Tel. No. Office Tel. No.
SIBLINGS BIRTH ORDER (Eldest to Youngest-including yourself)
Name Birthdate Occupation Company
       
       
       
Educational Background
Level School / Address Years Attended Honors Received Degree Earned
Elementary School / Address Years Attended Honors Received Degree Earned
Secondary School / Address Years Attended Honors Received Degree Earned
Collegiate School / Address Years Attended Honors Received Degree Earned
Graduate School / Address Years Attended Honors Received Degree Earned
Vocational School / Address Years Attended Honors Received Degree Earned
Other School / Address Years Attended Honors Received Degree Earned
Medical History
Indicate Medical History in the space provided below,
type NONE if not applicable:
Please answer YES or NO:
Allergies Allergies Do you smoke (cigarette or tobacco)? No
Cardiovascular Problems Cardiovascular Problems Do you drink alcohol? No
Gastrointestinal Problem Gastrointestinal Problem Have you undergone any operation? No
Personal/Family History of Mental Disorder Personal/Family History of Mental Disorder
Vision Problem Vision Problem
Respiratory Problem Respiratory Problem
OTHERS that are not listed above: OTHERS that are not listed above
Government Exam Taken
Examination Date Place Rating
       
       
       
Work Experience (Begin with the most recent employment)
From-To Company Address Tel. No. Salary Job Position Reason for Leaving
             
             
             
Salary Expectation Salary Expectation  
1. Which job did you enjoy the most? Why?   2. Was there anything that you particularly dislike about any of your jobs? Why?  
3. Give at least three reasons why GS should hire you. What values can you add to the company?   4. What are your expectations from GS?(Answer Below)