ACMI-CRW Form 01 / Rev 1 / 12 Dec 2013

AMINTA CREW MANAGEMENT, INC.

3F Coherco Corporate Center, 116 V.A. Rufino Street, Legaspi Village, 1229 Makati City, Metro Manila, Philippines
Tel. 845-0072 Fax. 845-0072 E-mail: operation@aminta.com.ph

April 3, 2018
DATE APPLIED: _______________________
1st Engr/1st Assistant
POSITION APPLYING FOR: ______________
Anytime
AVAILABILITY: ________________________
SEAFARER APPLICATION FORM

PERSONAL DATA
LAST NAME: FIRST NAME: MIDDLE NAME: CIVIL STATUS:
Lim Eudoxio Edquilang Married
PERMANENT ADDRESS: TEL NO.: CELLPHONE NO.:
Simeon Amodia St. Marigondon Lapu-Lapu City 0322362549 09560096466
CONTACT ADDRESS: E-MAIL ADDRESS: OTHER CONTACT NOS.:
Cebu City Philippines eudslim@gmail.com
DATE OF BIRTH: AGE: PLACE OF BIRTH: HEIGHT: WEIGHT: NATIONALITY:
Nov. 25, 1961 57 Ubay Bohol, Philippines 5’6” 75kg Filipino
SSS NO.: TIN NO.: PHILHEALTH NO.: PAG-IBIG NO.:
06-0757384-6 126-592-108-000 02-025577900-2 1210-7060-8106
WIFE’S FULL MAIDEN NAME: DATE OF BIRTH: PLACE OF BIRTH: CELLPHONE NO. / E-MAIL ADDRESS:
Zenaida I. Bonghanoy Sept. 22, 1966 Sogod Cebu, Philippines
1st CHILD GIVEN NAME: AGE: 2nd CHILD GIVEN NAME: AGE: 3rd CHILD GIVEN NAME: AGE: 4th CHILD GIVEN NAME: AGE:
Jane 32 Catherine 29 Eugene 28 Darwin 22
FATHER’S FULL NAME: DATE OF BIRTH: PLACE OF BIRTH: ADDRESS & CONTACT NUMBER:
Francisco T. Lim
MOTHER’S FULL MAIDEN NAME: DATE OF BIRTH: PLACE OF BIRTH: ADDRESS & CONTACT NUMBER:
Victoriana Edquilang
NEXT OF KIN: DATE OF BIRTH: PLACE OF BIRTH: ADDRESS & CONTACT NUMBER:

EDUCATION
YEAR
LEVEL NAME OF SCHOOL COURSE CITY/PROVINCE
GRADUATED
College CCC-Cebu AME-Graduate Cebu City 1980
LICENSES
LICENSE TYPE NUMBER DATE ISSUED VALID UNTIL
COP-MARINA / COC-TESDA
LIBERIA SIRB 1324277 23-Mar-17 23-Mar-22
LIBERIAN ENDORSEMENT
MALTA ENDORSEMENT
PANAMA SIRB
PANAMANIAN ENDORSEMENT
PHILIPPINE GOC
PRC CERTIFICATE OF COMPETENCY 37-4168 28-Dec-16 28-Dec-21
PRC ENDORSEMENT 43-4172 28-Dec-16 28-Dec-21
TRAVEL DOCUMENTS
DOCUMENT TYPE NUMBER DATE ISSUED VALID UNTIL
PASSPORT EC4815483 31-Jul-15 30-Jul-20
SIRB C09333077 16-Nov-17 15-Nov-26
SRC 0172397-94 14-Mar-17
U.S. VISA

TRAINING CERTIFICATES
NAC/COP CERTIFICATES NUMBER DATE ISSUED NAC/COP CERTIFICATES NUMBER DATE ISSUED
Advanced Training in Firefighting 17-43617 28-Dec-16 Basic Safety Training 24-167691 28-Dec-16
Medical Care Medical First Aid 18-189404 28-Dec-16
Proficiency in Survival Craft and Rescue 30-Jun-15
Proficiency in Fast Rescue Boats
Boats 28-Dec-16
Seafarers with Designated Security Duties
Ship Security Officer
with Security Awareness Training
TRAINING CENTER CERTIFICATES NUMBER DATE ISSUED TRAINING CENTER CERTIFICATES NUMBER DATE ISSUED
Anti-Piracy Awareness Training 15/AAPT_SB-29-566 28-Jul-15 ARPA
Auxiliary Machinery System Bridge Resource Management
Bridge Team Management Cargo Handling and Care of Cargo
Consolidated MARPOL 57-0913-1097 6-Sep-13 Control Engineering
Electronic Chart Display and Information Electronic Chart Display and Information
System (Generic) System (Specific) - DANELEC
Engine Room Resource Management Engine Room Simulator
Engine Room Simulator with Engine
Engineering Watchkeeping
Resource Management
Global Maritime Distress and Safety
Navigational Watchkeeping
System
Management Level Course (Function 1) UPD/MLC-E-F1-25-1216-
0401AM 16-Dec-16 Management Level Course (Function 2)
Management Level Course (Function 3) UPD/MLC-E-F3-31-1116-
0373AM 5-Nov-16 Management Level Course (Function 4)
RADAR Shielded Metal Arc Welding
Ship Simulator and Bridge Teamwork with
Ship Simulator and Bridge Teamwork
Bridge Resource Management
MEDICAL
MEDICAL CERTIFICATES NUMBER DATE ISSUED VALID UNTIL
Cholera
Yellow Fever QK081096 10-Jun-10 -
DETAILS OF SEA-GOING EXPERIENCE (Starting with the LATEST in chronological order)
Vessel Reason for Principal’s
Vessel Name Flag GRT DWT Year Built Engine Type BHP/KW Rank Sign-on Sign-off Months Trade Route Manning Agency
Type sign-off Co. Name
Bright
MV KYALAMI Bulk Monrovia
17025 B&W
7954 2E 17-Mar-17 11-Feb-18 11
Worldwide FC Maritime
MV STAR
POLARIS Bulk Majuro
97733 B&W
19620 2E 13-Mar-16 21-Oct-16 7
Worldwide FC Star Ocean

MV STAR
GAMMA Bulk Majuro
29295 B&W
10450 2E 06-Sep-17 16-Feb-16 5
Worldwide FC Star Ocean

Anglo
MV CAPE LILY Bulk Singapore
92752 B&W
18660 2E 21-Oct-14 06-Jun-15 8
Worldwide FC Eastern
MV CAPE Martial Anglo
AZALEA Bulk Island
106251 B&W
25388 2E 24-Nov-13 21-Aug-14 9
Worldwide FC Eastern
CAPE Magsaysay
JACARANDA Bulk Panama
92752 B&W
- 1AE 14-Feb-13 28-Jun-13 4
Worldwide FC Corporation
Bibby Ship
APHRODITE L Bulk Monrovia
44262 Sulzer Wasilla
- 2E 03-Jun-12 18-Oct-12 4
Worldwide FC Management

I HEREBY CERTIFY that the information above is true and correct. Any misrepresentation or misinformation on my part shall be grounds for the revocation of my application and if already employed, shall be ground for termination without any responsibility / liability on the part of AMINTA CREW
MANAGEMENT, INC. whatsoever.

Applicant’s Signature: ____________________________________ April 3, 2018

Date: ____________________________________