APPLICATION FORM

Date Filed JUNE 16, 2016

Position Applied for 1. OS

2. DECK BOY

PERSONAL DATA
Last Name First Name Middle Name Maiden Name
GIDUCOS ARGIE MONINO (for female Married applicants)

Nationality Date of Birth Place of Birth Height (cm.) Weight (kg.)

FILIPINO OCT 27,1990 NAVOTAS METRO MANILA 511 65
Preferred Nickname Shoe size Email address
11 giducosargie@yahoo.com.ph
SSS. No. PhilHealth No. PAG-IBIG No.
34-4053898-0 02-026632361-2 1211-0331-4834
Civil Status Single Sex Male
Permanent Address Alternative Address

BUHAY NA TUBIG IMUS CITY CAVITE

City Imus Cavite Zip Code City Zip Code

Contact No. 09461966895 Contact No.
FAMILY DETAILS
Name Sex Date of Birth Place of Birth
Father JERRY GIDUCOS M Sept 18,1968 Cebu
(Please indicate Middle Name)
Mother REBECCA GIDUCOS F Feb 7, 1969 Masbate
(Please indicate Maiden Name)
Spouse
(Please indicate Maiden Name)
Child/Children

Person to notify in case of emergency

Name: JERRY GIDUCOS Relationship: FATHER
Address: BNT IMUS CAVITE

Zip Code: Contact No 09109369734

EDUCATION BACKGROUND
Highest Degree Date
Level School Place
Earned From To
Collegiate/Vocational PMI COLLEGES BSMT 2009 2012 STA.CRUZ MNLA
Secondary

QSF 98/2010/Rev. 04
 APPLICATION FORM

RECORD BOOKS
Date
Document No. Issuing Authority
Issued Expiry
Passport (PH) EC3234589 JAN 22, 2015 JAN 21, 2020 DFA MNLA
Seamans Book (PH) COO80676 JUNE 6,2013 JUNE 5,2018 MARINA
SRC (PH)
US Visa
A. Have you ever been denied of any visa? Choose an answer
If yes, please provide the following details:
Country Date of Refusal Reason for refusal

B. Have you ever been deported? Choose an answer

If yes, please provide following details:
Country Date of deportation Reason for deportation

TRAINING COURSES
Issued Date
Training Name Document No. Issued Date Training Center With COP?
of COP
Basic Training APRIL
BT-15B81-09 ZRC 24-497903 DEC 1, 2015
17,2015
Basic Safety Course
Refresher for BT
Updating for BT
Proficiency in
Survival Craft and PSCRB-2016-3693 AUG 19, 2016 GLOBAL
Rescue Boat
Advanced
ATFF-15B64-13 NOV 26, 2015 GLOBE 17-223581 DEC 1,2015
Firefighting
Crowd OI-CRWD-0111-
DEC 11, 2012 OCEANLINK
Management 2012
Crisis Management OI-CRISIS-0125-
DEC 14, 2012 OCEANLINK
2012
Watchkeeping MDWK-065-15-
DEC 11, 2015 SIMS
9282
STSDSD OI-SDSD-2436-
NOV 25,2014 OCEANLINK 27-437599 DEC 1,2015
2014
OTHER TRAINING COURSES
Issued Date
Training Name Document No. Issued Date Training Center With COP?
of COP
MEFA MEFA-15B64-08 NOV 20. 2015 GLOBE 18-229214 DEC 1,2015
MARPOL CMP-17BO7-10 JAN 28, 2017 ZRC
BTOCT MNBOCT-042-16-
OCT 15, 2016 SIMS
3623

LICENSE / ENDORSEMENT
Date
Doc. No. Issuing Authority
Issued Expiry
NC I
National Certificate.
Rating in Watchkeeping OCT 21,
25-169465 MARINA
2016
Able Seafarer Deck/Engine
Electro-Technical
PH License 36-39968/42-45101 OCT 3, 2016 AUG MARINA

QSF 98/2010/Rev. 04
 APPLICATION FORM

22,2021
Flag State License
GOC (PH)
GOC (Flag State)
*Flag State 1. Bahamas 2. Panama 3. Singapore, Others
*Issuing Authority 1. MARINA 2. Bahamas Maritime, Others

QSF 98/2010/Rev. 04
 APPLICATION FORM

MEDICAL HISTORY
It is important that all illness other than minor afflictions should be stated. The Company is entitled to refuse any claim
treatment, cost or any other benefits if a complete statement of all previous illness has not been given.
A. Have you ever singed of a ship due to medical reason? Choose an answer
If yes, please provide following details:
Name of vessel: Date of occurrence: Place of occurrence:
Brief description of illness / injury / accident

B. Have you ever undergone any operation in the past? Choose an answer
If yes, please provide following details:
Details of operation Date Period of disability Present condition

C. What illness or accident have you consulted a doctor during the last 12 months?
Details of illness/accident Date Therapy / Treatment

D. Do you have any of the following conditions?

- Hypertension - Choose an answer
- Diabetes - Choose an answer
- HEPA A or B - Choose an answer
- Asthma - Choose an answer
E. Are you a smoker? Choose an answer

REFERENCES
Please give references from two recent employers who may we contact for references
Reference 1 Reference 2
Name of Company
Name of contact person FE CANUTO
Address ANTIPOLO
Contact No. 09956516749
Other Information
A. Do you have any relatives working with us at present? Choose an answer
If yes, please provide following details:
Name of crew Position and Principal Relationship

B. Have you ever applied for a job with us before? Choose an answer
If yes, please provide the following details:
When Position

I hereby declare that the above, including my Medical History is true.

ARGIE M. GIDUCOS
Signature over Printed Name

QSF 98/2010/Rev. 04
 APPLICATION FORM

PREVIOUS EMPLOYMENT
Please complete below with details of your previous employment for the past ten (10) years and provide a brief description of your specific duties and
responsibilities.
LAND / SEA EXPERIENCE (most recent first)
Address and Date
Rank/ Manning Employer/ Vessels Vessel Duties and
Contact No. of GRT
Position Agency Principal Name Type* From To Responsibilities
Manning Agency
M/V
DECK 2GO GROUP 11,191,1 NOV 18, NOV
TAFT AVENUE ST.FRANCIS RORO/PAX
CADET INC 1 2013 30,2014
XAVIER
2GO GROUP M/V ST,LEO JULY 15,
OS TAFT AVENUE RORO/PAX 19,468 JAN 11, 2016
INC THE GREAT 2016

*Legend:
GCD General Cargo
OBO Ore/Bulk/Oil Carriers
GAS LPG/LNG Gas Carriers
OSV Off Shore Supply Vessel
B/C Bulk Carrier CON Cellular Container MLP Multipurpose O/O Ore / Oil Carrier
TNC Tanker (Crude) TNP Tanker (Product) TNV VLCC/ULCC TNS Tanker (Storage)
CHM Chemical Carriers PAS Passenger Ship R/O Ro/Ro Carriers C/S - Car Ship
DRG Dredgers SRV Survey Vessel LOG Log / Timber RFR - Reefer

QSF 98/2010/Rev. 04