KNUTSEN PHILIPPINES EMPLOYMENT APPLICATION FORM

PHOTO (USING WEBCAM)*

NOTE:

- Click the Camera icon above to take photo. This will only work if you have webcam installed on the pc
- All fields with asterisk (*) should be filled up properly, otherwise you will not be able to submit the form.

TYPE OF APPLICATION*

NAME*

First Name Middle NameLast Name

CURRENT RANK*

POEA E-REGISTRATION NUMBER

CIVIL STATUS*

GENDER

PERMANENT ADDRESS*

POSTAL CODE*

TEMPORARY ADDRESS

POSTAL CODE

EMAIL ADDRESS*

LANDLINE NUMBER

Country CodeArea CodePhone Number

MOBILE NUMBER*

prefixPhone Number

DATE OF BIRTH*

Date

PLACE OF BIRTH*

FAMILY / NEXT OF KIN INFORMATION*

	NAME	BIRTHDAY MM/DD/YYYY
FATHER'S NAME
MOTHER'S MAIDEN NAME

FAMILY / NEXT OF KIN INFORMATION

	NAME	BIRTHDAY MM/DD/YYYY
SPOUSE NAME
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5

EMPLOYMENT EXPECTATIONS

	.
SALARY
TENURE OF CONTRACT
BENEFIT/S
FAMILY ASSISTANCE

HEALTH INFORMATION

	.
DATE OF RECENT MEDICAL EXAMINATION (MM/DD/YYYY)
MEDICAL CLINIC
HEIGHT (In Ft)
WEIGHT (In Kg)

QUALIFICATION INFORMATION

Note: Please input other documents, courses and certificate, not shown on the default list given, at the buttom of this page.

	DOCUMENT NUMBER	ISSUANCE DATE MM/DD/YYYY	VALIDITY MM/DD/YYYY
SSS NO.
PHILHEALTH NO.
TIN
PASSPORT NO

	DOCUMENT NUMBER	ISSUANCE DATE MM/DD/YYYY	VALIDITY MM/DD/YYYY	RANK
SIRB NO
SRC NO
US C1 / D VISA
YELLOW FEVER VACCINE

	CERTIFICATE NUMBER	VALID UNTIL MM/DD/YYYY
STCW CERTIFICATE OF COMPETENCY NO.
STCW CERTIFICATE OF ENDORSMENT NO.

Note: If you dont have STCW certificate, please put NA

	CERTIFICATE NUMBER	VALID UNTIL MM/DD/YYYY
STCW LICENSE LIMITATION (OFFICER)
HIGHEST STCW CERTIFICATE HELD (RATING)/ LICENSE NO.:
GENERAL OPERATOR’S CERTIFICATE NO.:

CERTIFICATE OF PROFICIENCY

	CERTIFICATE NUMBER	VALIDITY MM/DD/YYYY
BASIC TRAINING
SHIP SECURITY AWARENESS TRAINING AND SEAFARERS WITH DESIGNATED SECURITY DUTIES

	CERTIFICATE NUMBER	VALIDITY MM/DD/YYYY
PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOAT
PROFICIENCY IN FAST RESCUE BOAT
ADVANCED TRAINING IN FIRE FIGHTING
MEDICAL FIRST AID
MEDICAL CARE
SHIP SECURITY OFFICER
BASIC TRAINING IN OIL AND CHEMICAL TANKER CARGO OPERATIONS
BASIC TRAINING IN LIQUEFIED GAS TANKER CERTIFICATE
ADVANCED TRAINING IN OIL TANKER CARGO OPERATION
ADVANCED TRAINING IN CHEMICAL TANKER CARGO OPERATION
ADVANCED TRAINING IN LIQUEFIED GAS TANKER CARGO OPERATION
ABLE SEAFARER- ENGINE
ABLE SEAFARER- DECK

FLAG STATE DOCUMENTS

	CERTIFICATE NUMBER	VALIDITY MM/DD/YYYY
NIS BOOKLET
NIS LICENSE ENDORSEMENT
NIS TELENOR
NIS TANKERMAN HIGHEST GRADE
UK LICENSE ENDORSEMENT
UK GMDSS CERTIFICATE
ISLE OF MAN ENDORSEMENT
MALTA SEAMAN’S BOOK
MALTA ENDORSEMENT
BAHAMAS SEAMAN’S BOOK
BAHAMAS ENDORSEMENT
BAHAMAS TANKERMAN HIGHEST GRADE
DENMARK ENDORSEMENT

STCW COURSES

	VALIDITY MM/DD/YYYY
BASIC TRAINING
BASIC TRAINING- UPGRADING
BASIC TRAINING- REFRESHER
BASIC SAFETY COURSE WITH PSSR
PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOAT
PROFICIENCY IN FAST RESCUE BOAT
ADVANCED TRAINING IN FIRE FIGHTING
MEDICAL CARE
SHIP SECURITY OFFICER
SHIP SECURITY AWARENESS TRAINING AND SEAFARERS WITH DESIGNATED SECURITY DUTIES
BASIC TRAINING IN OIL AND CHEMICAL TANKER CARGO OPERATIONS
BASIC TRAINING IN LIQUEFIED GAS TANKER CERTIFICATE
ADVANCED TRAINING IN OIL TANKER CARGO OPERATION
ADVANCED TRAINING IN CHEMICAL TANKER CARGO OPERATION
ADVANCED TRAINING IN LIQUEFIED GAS TANKER CARGO OPERATION
GENERAL TANKER COURSE
SHORE BASED FIRE FIGHTING
SPECIALIZED TRAINING IN OIL TANKER
SPECIALIZED TRAINING IN CHEMICAL TANKER
SPECIALIZED TRAINING IN LIQUIEFIED TANKER

SHUTTLE TANKER COURSES & COMPANY REQUIREMENTS

	VALIDITY MM/DD/YYYY
DYNAMIC POSITIONING LICENSE
BLS PH. 1
BLS PH. 2
BLS PH. 3
POSITION REFERENCE SYSTEM
HELICOPTER LANDING OFFICER
DGPS/DARPS OPERATOR
DGPS/DARPS MAINTENANCE
BLOM PMS
BLS PUSNES
ARTEMIS OPERATOR
ARTEMIS MAINTENANCE
DYNAMIC POSITIONING- BASIC
DYNAMIC POSITIONING- ADVANCED
TELEMETRY
FSE HIGH VOLTAGE
HIGH VOLTAGE CLASSROOM
RISK ASSESSMENT CLASSROOM
ROOT CAUSE ANALYSIS CLASSROOM
TM MASTER
MAIN ENGINE MAN B&W
MAIN ENGINE MAN MC

TRAINING CERTIFICATES - DECK

	ISSUANCE DATE MM/DD/YYYY
AUTOMATIC IDENTIFICATION SYSTEM
AUTOMATIC RADAR PLOTTING AID
BRIDGE RESOURCE MANAGEMENT
COLLISION AVOIDANCE
ELECTRONIC CHART DISPLAY INFORMATION SYSTEM
ECDIS SPECIFIC- SPERRY MARINE
ECDIS SPECIFIC- TECDIS FURUNO
ECDIS SPECIFIC- JRS
ECDIS SPECIFIC- KONGSBERG
FRAMO OPERATOR/MAINTENANCE
GENERAL OPERATOR CERTIFICATE/ GMDSS
HULL INSPECTION/ STRUCTURE
ICE NAVIGATION BASIC
MARITIME CREW RESOURCE MANAGEMENT
MARITIME ADMINISTRATION
MARITIME LAW FOR SHIP OFFICERS
RADAR OBSERVATION AND PLOTTING
SHIP SIMULATOR AND BRIDGE TEAMWORK
RATINGS FORMING PART OF NAVIGATIONAL WATCH
TRIM AND STABILITY

TRAINING CERTIFICATES - ENGINE

	ISSUANCE DATE MM/DD/YYYY
AUXILLIARY MACHINERY SYSTEM
ADVANCED WELDING COURSE
BILGE WATER/ WASTE OIL OPER. MANAGEMENT
CONTROL ENGINEERING
ENGINE-ROOM RESOURCE MANAGEMENT
ENGINE ROOM SIMULATOR
FRAMO OPERATOR/MAINTENANCE
HYDRAULICS/PNEUMATICS
HULL INTEGRITY/STABILITY
MARPO
RATINGS FORMING PART OF ENGINEERING WATCH

OTHER CERTIFICATES / COURSES / FLAG STATE DOCUMENTS (If not listed on the default list given)

	NAME OF CERTIFICATE / COURSE / DOCUMENT	CERTIFICATE NUMBER	VALIDITY MM/DD/YYYY	ISSUING COUNTRY	REMARKS
.
.
.
.
.
.
.
.
.
.
.

EMPLOYMENT EXPERIENCE

	VESSEL NAME	VESSEL TYPE	RANK	FLAG	SIGN ON MM/DD/YY	SIGN OFF MM/DD/YY	GRT	KWT	MAIN ENGINE	MANNING AGENT	PRINCIPAL NATIONALITY

EMPLOYMENT REFERENCES ( Please provide at least two (2) references)*

	COMPANY	NAME	DESIGNATION	OFFICE CONTACT NO.	MOBILE NO / EMAIL ADDRESS	REASON FOR LEAVING
.

ADDITIONAL REFERENCES

	COMPANY	NAME	DESIGNATION	OFFICE CONTACT NO.	MOBILE NO / EMAIL ADDRESS	REASON FOR LEAVING
.

TERMS AND CONDITIONS

I hereby give my consent to Knutsen Philippines to process my personal information for the purpose of my employment

I hereby attest under penalty or perjury that all information and details i have indicated herewith are true and accurate at the date in which i fill up this documents. I fully undestand and accept that the risk and consequence for the acts of deliverate falsification of information and fraud include, but are not limited to, the automatic rejection of my application and / or employment opportunity which may be accorded unto me.

APPLICATION FORM (NON EXPERIENCE)