Seafarer Application Form

* Fields are mandatory


Latest Sea Service

Civil Status

Medical History

(a) Have you ever signed off from a ship due to Medical reasons ( If Yes give details) Yes No
(b) Did you suffer or Are you Presently suffering from any Disease likely to render you unfit for Service at Sea or likely to endanger the health of others on board. Yes No
(c) Are you addicted to alcohol or drugs of any kind. Yes No
(d) Have you suffered from following Malaria Diabetes Epilepsy Nervous Disability
(e) Did you ever undergo physhiatric treatment : Yes No

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