AC-56

12 October 2018
Rev. 1
Rev. 0

NAMEI POLYTECHNIC INSTITUTE

123 A. Mabini St. Mandaluyong City

PRIVACY NOTICE: Any personal data you have provided will only be used by NAMEI in the pursuit of its legitimate
interest as an educational institution. All collected data will be treated with utmost security and confidentiality unless
authorized by law. NAMEI respect your rights under the Data Privacy Act. Questions and clarifications relative to privacy
and data protection, you may contact us at namei.dpo@gmail.com.

SHIPBOARD TRAINING APPLICATION FORM

I. PERSONAL DATA

NAME: __________________________________________________________________________
ADDRESS: __________________________________________________________________________
CONTACT NO.: __________________________________________________________________________
DATE OF BIRTH: __________________________________________________________________________
FATHER’S NAME: _________________________________OCCUPATION:_____________________________
MOTHER’S NAME: _________________________________OCCUPATION:_____________________________
NUMBER DATE ISSUED
SSS NO.: __________________________________ ___________________________________
TIN NO.: __________________________________ ___________________________________
PHILHEALTH NO.: __________________________________ ___________________________________
PAG-IBIG NO.: __________________________________ ___________________________________

II. TRAINING/S ATTENDED

DATE ISSUED TRAINING CENTER

Deck Watch keeping __________________________ ________________________________
Engine Watch keeping ________________________ __ ________________________________
SDSD-Security ________________________ __ ________________________________
Marpol-Consolidated ________________________ __ ________________________________
BT-Basic Training ________________________ __ ________________________________
PSCRB-Rescue Boat ________________________ __ ________________________________
MEFA-First Aid ________________________ __ ________________________________
ATFF-Fire Fighting __________________________ ________________________________

III. OTHER LICENSES/REQUIREMENTS:

DATE ISSUED CERTIFICATE NUMBER

COC-Certificate of _________________________ ________________________________
Competent
OJT-On-The-Job Training _________________________ ________________________________
Certificate
SRC-Seaman Registration _________________________ ________________________________
Passport _________________________ ________________________________
Seaman Book _________________________ ________________________________
Yellow Fever _________________________ ________________________________
NSO Birth Certificate _________________________ ________________________________

_____________________________
SIGNATURE ABOVE PRINTED NAME