notes

1. PART VII - DETAILS OF SEA-GOING EXPERIENCE (Starting with the LATEST in chronoligical order)
MAIN ENGINE PERIOD(dd-mm-yr)
Vessel Name Vessel Type Flag GRT DWT
Year
Built Maker Type or Model BHP Rank Sign-on Sign-off Months Trade Route Reason for sign-off
Vessel Name Vessel Type Flag GRT Column1 Year Built Maker Type BHP Rank Sign-on Sign-off Months Trade Route Reason for sign-off
MV STAR JEANNETE BULK MONROVIA 45,223 2014 MAN B&W 6S60ME-C8.2 9660KW 2/E 27-Nov-21 27-Apr-22 5 WW F.C
AOM GEORGINA BULK SINGAPORE 43,022 2014 MAN B&W 6S60MC 9710KW 2/E 29-Nov-20 5-Aug-21 8 WW F.C
MV UNION ANTON BULK MAJURO 19,785 2015 MITSUBISHI LS50 6,840KW 2/E 29-Mar-19 26-Jan-20 10 WW F.C
M/V ENGLISH BAY BULK HONGKONG 19925 2000 MITSUBISHI LS46 6619 2/E 21-Jan-18 12-Jul-18 6 WW F.C
MV FERNANDINA BULK LIBERIA 88853 2006 MAN B&W MC 16860 2/E 5-Feb-17 24-Jul-17 6 WW F.C
M/V ALAB SINAR BULK SINGAPORE 21699 2013 MAN B&W 6S60MC 5440 2/E Feb 19 2016 8-Nov-16 9 WW F.C
MV SERENITAS N BULK MAJURO 33032 2011 RT/flex RT/flex50 8794 2/E 06/15/15 Oct 17 15 4 WW F.C
MV KM HAKATA BULK SINGAPORE 50626 2013 MAN B&W 6S60ME-C8.2 12590 2/E 12-Jul-14 FEB O7 2015 7 WW F.C
0
PART VIII - CONTACT DETAILS OF AT LEAST 3 FOREIGN PRINCIPALS
COMPANY NAME OFFICE ADDRESS E-MAIL ADDRESSES / FAX NUMBER
PART IX - DETAILS OF WORK EXPERIENCE ASHORE, IF ANY
COMPANY NAME & ADDRESS POSITION FROM TO JOB DESCRIPTION
PART X - MEDICAL BACKGROUND
YES NO (IF YES, PLEASE DESCRIBE)
Please type "X"
Any Previous Surgery?
Any Previous Serious Illness / Injury / temporary disability?
Any Physical Handicap?
Any Drug Related Problem?
Any Alcohol Related Problem?
Any involvement in an accident resulting to loss of life or
personal injury or damage to ship, cargo, pollution, etc.?
NOTE: In case and in the event that I withdraw my do
principal, I hereby agree to pay and reimburse all the e
cost (POEA Contract, PEME, Visa, Flags, Trainings and o
withdrawal is due to the fault of the principal or the co
be affected within five (5) working days after the reque
all fees and cost have been paid.
PART XI - CHARACTER REFERENCES
NAME / POSITION COMPANY NAME / ADDRESS CONTACT NUMBERS / E-MAIL
I HEREBY, certify that I have not been involved, charged or convicted in any administrative civil and/or criminal or tribunal in any jurisdiction either local or international in connection with my employment as a seafarer onboard ocean going vessel.

2. I futher certify that I have not been involved, charged or convicted in any administrative, civil or criminal court or tribunal for cases associated with magic pipes and other similar activities in any U.S. Jurisdiction neither was I been deported or placed under blacklis
by the U.S. Coast Guard and or the U.S. Environmental Protection Agency as consequence thereof.
I HEREBY CERTIFY that the information above is true and correct. Any misrepresentation or misinformation on my part shall be grounds for the revocation of my application and if already employed, shall be ground for termination without any responsibility / liabilit
Crewing Services, Inc. whatsoever.
Applicants Signature ____________________________________ Date: 06/07/22

3. Manning Agency Principal's Co. Name
Manning Agency Principal's Co. Name
AUGUSTEA IBLEA
CAMII GOPL
PANDISHIP UCI
PB MARITIME PB
CARDIFF TSM
CAMII GOPL
SYNERGYGROUP CSM
SYNERGYGROUP GOPL
L ADDRESSES / FAX NUMBER PERSON-IN-CHARGE
REASON FOR LEAVIING
n the event that I withdraw my documents after approval by the
ree to pay and reimburse all the expenses for processing fees and
PEME, Visa, Flags, Trainings and other Certificates) Unless the
the fault of the principal or the company. Document release shall
ve (5) working days after the request is made, provided further that
e been paid.
ocean going vessel.

4. een deported or placed under blacklist
tion without any responsibility / liability on the part of Global Gateway