|
| |
| 3 Telephone / Fax no.: |
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| 4 Contact person: |
|
| 2. Details of employer’s agent: |
5 Telephone / Fax no.: |
|
| 1 Name: |
6 CDC no. / Place of issue: |
|
| 2 Postal address & e-mail:
|
7 CDC date of issue / expiry: |
|
| 8 Passport no. / Place of issue: |
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| 9 PP date of issue / expiry: |
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| 8. Details of next of kin: |
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| 3 Telephone / Fax no.: |
1 Name / Relationship: |
|
| 4 Contact person: |
2 Postal address & e-mail: |
|
| 3. Details of ship: |
|
| 1 Name: |
|
| 2 Port of registry / trade: |
|
| 3 Official / IMO no.: |
3 Telephone / Fax no.: |
|
| 4 G.T. / Power (Kw / BHP): |
9. Details of certificates: |
|
| 5 No. of crew including master: |
1 COC grade / no.: |
|
| 4. Details of employment: |
2 Place of issue: |
|
| 1 Rate of monthly wages on board: |
3 Date of issue / expiry: |
|
| 2 Rate of monthly PF / gratuity: |
4 Limitations (if any): |
|
| 3 Amount of monthly allotment: |
|
| 4 Capacity / Rank employed: |
10. Details of special ship type endorsement (if applicable): |
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| 5 Reason for signing-off: |
1 Type of endorsement: |
|
| 6 Paid off on date …………………Place. ………………………… |
2 Level / Certificate no.: |
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| 7 PF contribution due ……………………………………………… |
3 Place of issue: |
|
| 8 Gratuity (SWFS) due………………………..…………………… |
4 Date of issue / expiry: |
|
| 5. Signature with date & stamp of employer/employer’s agent: |
11. Signature of seafarer with date: |
|
| 1 Signed-on ashore:
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