APPLICATION FORM

Date Filed Oct.11,2017

Position Applied for 1. Assistant Electrician

2.

PERSONAL DATA
Last Name First Name Middle Name Maiden Name
PAREDES LINTON BALLESTA (for female Married applicants)

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

PILIPINO Nov,04,1994 SAN RAFAEL,ILO ILO 170cm 56kls
Preferred Nickname Shoe size Email address
TON2 Lintonparedes20172@gmail.com
SSS. No. PhilHealth No. PAG-IBIG No.
09-34060022 16-025684776-8 1211-4779-9449
Civil Status Single Sex Male
Permanent Address Alternative Address
TINA,SAN MIGUEL,SURIGAO DEL SUR TINA,SAN MIGUEL,SURIGAO DEL SUR

City Zip Code 8301 City Zip Code 8301

Contact No. Contact No.

FAMILY DETAILS
Name Sex Date of Birth Place of Birth
Father RENA B. PAREDES MALE JAN.25,1954 BAROTAC VEIJO,ILOILO
(Please indicate Middle Name)
Mother ERLINDA B. PAREDES FEMALE NOV.11,1954 MONTAY
(Please indicate Maiden Name) MIDSAYAP,COTABATO
Spouse
(Please indicate Maiden Name)
Child/Children

Person to notify in case of emergency

Name: ERLINDA B. PAREDES Relationship: MOTHER
Address: TINA,SAN MIGUEL,SURIGAO DEL SUR

Zip Code: 8301 Contact No 09058619248

EDUCATION BACKGROUND
Highest Degree Date
Level School Place
Earned From To
Collegiate/Vocational
Secondary BANISILAN 2007 APRIL BANISILAN NORT
NATIONAL HIGH 8,2011 COTABATO
SCHOOL

QSF 98/2010/Rev. 04
 APPLICATION FORM

RECORD BOOKS
Date
Document No. Issuing Authority
Issued Expiry
Passport (PH) P1744438A JAN.25,2017 JAN.24,2022 DFA-DAVAO
Seaman’s Book (PH) C1037828 MAY 3,2017 MAY 1,2027 MARINA
SRC (PH)
US Visa
A. Have you ever been denied of any visa? No
If yes, please provide the following details:
Country Date of Refusal Reason for refusal

B. Have you ever been deported? No

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-17B51-17 GLOBE MARITIME
25,2017
Basic Safety Course
Refresher for BT
Updating for BT
Proficiency in
Survival Craft and
Rescue Boat
Advanced
Firefighting
Crowd
Management
Crisis Management
Watchkeeping
STSDSD

OTHER TRAINING COURSES

Issued Date
Training Name Document No. Issued Date Training Center With COP?
of COP
ELECTRICAL
INSTALLATION
14110202002903 OCT.16,2014 PTC-DAVAO
AND
MAINTENANCE

LICENSE / ENDORSEMENT
Date
Doc. No. Issuing Authority
Issued Expiry
NC I
National Certificate.
Rating in Watchkeeping
Able Seafarer Deck/Engine
Electro-Technical
PH License
Flag State License
GOC (PH)
GOC (Flag State)
*Flag State 1. Bahamas 2. Panama 3. Singapore, Others

QSF 98/2010/Rev. 04
 APPLICATION FORM

*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? No
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? No

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 - No
- Diabetes - No
- HEPA A or B - No
- Asthma - No
E. Are you a smoker? No
REFERENCES
Please give references from two recent employers who may we contact for references
Reference 1 Reference 2
Name of Company ASIAPRO
Name of contact person WILLOW BRINGAS
Address MATINA,DAVAO CITY
Contact No. 09178179964
Other Information
A. Do you have any relatives working with us at present? No
If yes, please provide following details:
Name of crew Position and Principal Relationship

B. Have you ever applied for a job with us before? No

If yes, please provide the following details:
When Position

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

LINTON B. PAREDES
Signature over Printed Name

QSF 98/2010/Rev. 04

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.
Rank/ Manning
Position Agency
*Legend:
GCD – General Cargo
OBO – Ore/Bulk/Oil Carriers
GAS – LPG/LNG Gas Carriers
OSV – Off Shore Supply Vessel
APPLICATION FORM
LAND / SEA EXPERIENCE (most recent first)
Address and Contact Date
Employer/ Vessel’s Vessel
No. of Manning GRT Duties and Responsibilities
Principal Name Type* From To
Agency
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