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KSEB Consent Form for Seafarers

This document appears to be an application form for employment as a seafarer. It requests basic personal information like name, address, contact details, education history, licenses and certifications. It also includes declarations by the applicant that the information provided is accurate, and that previous employers may be contacted for references. The applicant agrees to assessments and sharing of information as part of the application and hiring process.

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Vhie Gutz
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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441 views2 pages

KSEB Consent Form for Seafarers

This document appears to be an application form for employment as a seafarer. It requests basic personal information like name, address, contact details, education history, licenses and certifications. It also includes declarations by the applicant that the information provided is accurate, and that previous employers may be contacted for references. The applicant agrees to assessments and sharing of information as part of the application and hiring process.

Uploaded by

Vhie Gutz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Page of:

1 2
830a Application Form

Rank / Position Applied

Last Name

First Name
Passport Photo
Middle Name
Residential Address
Civil Status Mobile Phone Number

Phone (Land line) Other Contact Number

Email Address Name of School


Highest Education
Year Attended (From-To)
Attainment

Seaman’s Book Date issued


Number Expiry Date
Date Issued
Passport Number
Expiry Date
US VISA Date Issued Expiry Date

DECLARATION
I certify that the above information and attached sea service record are true and accurate; and that
any false information would lead to the nullity and denial of this application.

That all Certificates of Competence or Licenses presented have never been revoked and/or suspended.

I agree that during this application process, I will be subjected to a computer based Professional and
English Language assessment test. The results of which form part of this application.

I agree that previous employers may be contacted for information concerning my employment record
and hereby release them from any liability and confidentiality in providing such information.

In compliance with the Data Privacy Act of 2012 (RA 10173), I agree that ALL information regarding
myself may be shared for hiring / processing and documentation purposes with the principal and all
internal interested parties, Philippine Government Agencies (e.g. POEA, OWWA, DFA, MARINA, SSS)
and other external interested parties (e.g. AMOSUP, P&I Clubs and Correspondents, HMO, Flag State
Authorities, Medical Assessment and Diagnostic Centers).

Signature over printed name Date

ZEAMSP-Form 830a | 19 June 2019 Rev: 00


Page of:
2 2
830a Application Form

Sea Service Record


(most recent vessel first)

Vessel’s M.E.
DWT Signed Signed No.
Foreign Local Rank Name Type of Trade Make Nat. of Nat. of Cause of
& on off of
Principal Agency Served & vessel Route & Officers Ratings Discharge
GRT (dd/mm/yy) (dd/mm/yy) months
Flag KW

ZEAMSP-Form 830a | 19 June 2019 Rev: 00

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