CU-QMS-STO-012

Capitol University
College of Maritime Education
Cagayan de Oro City
Personal Information Form
For Shipboard Training Enrollment
(Apprenticeship)
_______ Semester, School Year ______
1st Enrolment:
2nd Enrolment:

1x1
Colored
Picture

______ Semester, School Year ______

______ 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 the
documents submitted in support thereof are true and correct, and that I am fully aware and
bind myself that any false information shall render me liable for criminal prosecution and/or
invalidation of the Shipboard Training Enrolment.
___________________________________
Signature of Student/Representative
(Sign Over Printed Name)
Issue: 05 April06

Revision: 05