8/2/2019 cu-qms-sto-012

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CU-QMS-STO-012

Capitol UniversityCollege of Maritime Education

Cagayan de Oro City

Personal Information Form

For Shipboard Training Enrollment

(Apprenticeship)_______ Semester, School Year ______

1st Enrolment: ______ Semester, School Year ______2nd Enrolment: ______ Semester, School Year ______

Name: ______________________________________________________________

Last Name First Name Middle Name

Course: ________________ Seafarers Book No.: _______________________

Home Address: ______________________________________________________

______________________________________________ Tel #: ______________

Year Finished Academic Requirements (2nd/3rd Yr. Cur.)________________

Name of Vessel: ___________________________ Call Sign: _____________

Type of Vessel: __________IMO #: ______ GRT: _______ BHP/Kw:________

Duration of Contract: __________________ Position Held: ____________

Ships Mailing Address: ____________________________________________

____________________________________________________________________

Name of the Company: _______________________________________________

Company Address: ___________________________________________________

______________________________________________ Tel.#: ______________

Name of the Manning Agency: ________________________________________

____________________________________________________________________

Manning Agency Address: ____________________________________________

_______________________________________________Tel.#: ______________

I hereby certify that all information and statements provided by me including thedocuments submitted in support thereof are true and correct, and that I am fully aware andbind myself that any false information shall render me liable for criminal prosecution and/orinvalidation of the Shipboard Training Enrolment.

___________________________________Signature of Student/Representative(Sign Over Printed Name)

Issue: 05 April06 Revision: 05

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