Thanks to visit codestin.com
Credit goes to www.scribd.com

0% found this document useful (0 votes)
21 views7 pages

SMM Sign-On Form: Forms and Check Lists

The document is a Sign-On Form for crew member BODNARI ION, detailing personal data, qualifications, and medical documents required for joining the ship Rawaq under the Saudi Arabian flag. It includes sections on personal documents, national documents, flag state documents, medical documents, and training documents, all of which must be checked and verified. The form also contains declarations regarding the crew member's health and compliance with recruitment policies.

Uploaded by

Jimmi Hendrix
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
21 views7 pages

SMM Sign-On Form: Forms and Check Lists

The document is a Sign-On Form for crew member BODNARI ION, detailing personal data, qualifications, and medical documents required for joining the ship Rawaq under the Saudi Arabian flag. It includes sections on personal documents, national documents, flag state documents, medical documents, and training documents, all of which must be checked and verified. The form also contains declarations regarding the crew member's health and compliance with recruitment policies.

Uploaded by

Jimmi Hendrix
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 7

PAGE: OF:

SMM
Forms and Check Lists 1 7
Document: Release:
F 03-03 Sign-On Form 19

Ship's Rawaq Flag: Saudi Arabia Date of 29.04.2025


Name: Embarkation:

1. Personal data

Name: BODNARI ION []


checked
Age (over 18 years old): [ ] Yes [ ] No []
checked
Function on board: Second Engineer []
checked
Date and Place of birth: 25.01.1987 Moldova. []
checked
Nationality: ROMANIAN []
checked
Gender: [ ] Male [ ] Female []
checked
Years of seagoing experience, shore []
side profession and professional checked
experience:
Name and address of next of kin Amurgului 33, Jechiu Natalia - sister, +373 []
79922802 checked
Manning agent: STARGATE CREWING AGENCY []
checked
Are the bank details in DB? / If yes, are [ ] yes [ ] no / [ ] yes [ ] no []
up to date? checked

2. Personal documents & Visas

Type of document Document No. Valid until


Passport 060724156 25.11.2031 [ ]
checked
Is the country of joining visa needing? [ ] yes [ ] no []
checked
Is the country of joining LOG needing? [ ] yes [ ] no []
checked
If needed visa, are checked the [ ] yes [ ] no []
requirements? checked
USA Visa C1 + D (Compulsory if no other 11.12.2027 [ ]
advise from Owners!) checked
MCV - Australia Maritime Crew Visa []
checked
Is the crew traveling with 4 photos, charged [ ] yes [ ] no []
battery &cash ? checked
Covid - 19 PPE(face marks, hand sanitiser, [ ] yes [ ] no []
gloves, googles) checked
PAGE: OF:
SMM
Forms and Check Lists 2 7
Document: Release:
F 03-03 Sign-On Form 19

Safety Equipment [ ] yes [ ] no []


checked

3. National Documents

Type of document Document No. Valid until


National Seaman's Book 30651ct 07.10.2028 [ ]
checked
National License & Endorsement 0100512 17.01.2030 [ ]
checked
Certificate of Competence (Diploma) 86203 17.02.2030 [ ]
checked
Tanker endorsements as per vessel’s class. [ ] yes [ ] no []
If the vessel has double class (ie checked
oil/chemical/gas), Endorsements must be
available!
National Health Certificate []
checked
National GMDSS Certificate []
checked

4. Flag State Documents (Flag: SAUDIARABIA)

Type of document Applicable Document No. Valid until


Flag state COC Endorsement [ ] yes [ ] no []
checked
Flag State Seaman’s Book [ ] yes [ ] no []
checked
Flag state CRA [ ] yes [ ] no []
checked
Flag State SQC (Special [ ] yes [ ] no []
Qualification Certificate) checked
Flag State GMDSS Endorsement [ ] yes [ ] no []
checked
If no Flag State dox, applied on [ ] yes [ ] no []
internet system? checked
Tanker endo as per vessel’s class. [ ] yes [ ] no []
If the vessel has double class (ie checked
oil/chemical/gas), both
Endorsements must be available!
Type of document Applicable Document No. Valid until
Flag state COC Endorsement [ ] yes [ ] no []
checked
Flag State Seaman’s Book [ ] yes [ ] no []
checked
Flag state CRA [ ] yes [ ] no []
checked
PAGE: OF:
SMM
Forms and Check Lists 3 7
Document: Release:
F 03-03 Sign-On Form 19

Flag State SQC (Special [ ] yes [ ] no []


Qualification Certificate) checked
Flag State GMDSS Endorsement [ ] yes [ ] no []
checked
If no Flag State dox, applied on [ ] yes [ ] no []
internet system? checked
Tanker endo as per vessel’s class. [ ] yes [ ] no []
If the vessel has double class (ie checked
oil/chemical/gas), both
Endorsements must be available!

5. Further Medical Documents

Type of document Applicable Document No. Valid until


Drug and Alcohol Test [ ] yes [ ] no []
checked
Masters-C/ Eng. valid EKG [ ] yes [ ] no []
checked
Post-Employment blood test (for [ ] yes [ ] no []
Oil/ Chemical Tankers) checked
Yellow fever vaccination [ ] yes [ ] no []
checked

6. Training Documents

Type of document Applicable Document No. Valid until


Basic Safety Training [ ] yes [ ] no 00000969 17.01.2030 [ ]
- Personal Safety and Social checked
Responsibility
- Proficiency in Personal Survival
Techniques
- Fire Prevention and Fire Fighting
-Elementary First Aid
Advanced Fire Fighting [ ] yes [ ] no 00000454 22.01.2030 [ ]
checked
Proficiency in Survival Craft [ ] yes [ ] no 00001076 24.01.2030 [ ]
&Rescue Boat checked
Medical Care Certificate – for [ ] yes [ ] no 00009013 []
Reederei Nord B.V. , certificate checked
(Master/2O) must be renewed every
5 years.
Bridge Team and Resource [ ] yes [ ] no []
Management – for Reederei Nord checked
Shipmanagement LTD, Cyprus
Ship Security Officer Certificate [ ] yes [ ] no 00016416 []
checked
Human Element, Leadership [ ] yes [ ] no 00003888 []
PAGE: OF:
SMM
Forms and Check Lists 4 7
Document: Release:
F 03-03 Sign-On Form 19

&Management checked
Dangerous Cargo [ ] yes [ ] no []
Handling(“Hazmat”) checked
HAZMAT CFR 49 Certificate [ ] yes [ ] no []
checked
ARPA Certificate [ ] yes [ ] no []
checked
ECDIS Certificate [ ] yes [ ] no []
checked
Medical First Aid [ ] yes [ ] no 00000727 []
checked
Prevention of Pollution of the [ ] yes [ ] no 00002784 17.03.2025 [ ]
Marine Environment - MARPOL checked
73/78
ISF MARLINS TEST & TEST OF [ ] yes [ ] no []
SPOKEN ENGLISH checked
HUET / BOSIET / FOET [ ] yes [ ] no []
checked
DP Basic / Advance / Unlimited [ ] yes [ ] no []
checked
DP Maintenance [ ] yes [ ] no YES []
checked
High Voltage Course [ ] yes [ ] no []
checked
Ro-ro Passenger ships / Passenger [ ] yes [ ] no []
Ships other than RO-ro Passenger checked
Ship
Maritime English [ ] yes [ ] no []
checked
SHIP HANDLING AND [ ] yes [ ] no []
MANEUVERING SIMULATION checked
Security Awareness Training [ ] yes [ ] no 00016416 []
checked
Digital Library on board Tankers – [ ] yes [ ] no []
for Reederei Nord B.V. checked
CES test Certificate [ ] yes [ ] no []
checked
Entering sea service in Data Base [ ] yes [ ] no YES []
checked
Copy of dox in Data Base [ ] yes [ ] no YES []
checked

7. Remarks

I declare that on my best knowledge that I was / was not signed off on medical reasons.
If yes, please advise on which medical reasons and provide with a medical statement that now
you are fit for duty
PAGE: OF:
SMM
Forms and Check Lists 5 7
Document: Release:
F 03-03 Sign-On Form 19

Signature:

8. Remarks

I declare that on my best knowledge that I am not suffering from any disease likely to be
aggravated by, or to render me unfit for service at sea or likely to endanger the health of other on
board. Furthermore, I declare that I am not taking any medication that has side effects that will
impair judgement, balance or any other requirements for effective and safe performance of
routine and emergency duties on board.

I declare that I do not have any flu - like symptoms / enter in contact with any person suffering
from COVID 19 and that I stayed isolated last 14 days, prior joining.

I declare that I will have a COVID-19 kit with me during the transit from hometown to vessel,
including: Face Masks(Disposable) – min 5pcs, Hand Sanitiser – containing minimum 70 %
alcohol, Gloves(disposable), Googles

Signature:

9. Remarks

I, undersigned, confirm that costs such as: medical/vaccination, transportation from/to airport,
airplane tickets, costs related to obtaining visa, processing documents are on owner account and
that I haven’t paid or even promised to any legal entity or any private person ANY fee for joining, or
employment, or any other matters connected to my embarkation. I hereby declare that I was not
subject of exploitation by the agency or it’s employees with regards to the offer received on any
shipping owner/manager and the offer of engagement accepted was fully studied, acknowledged
and accepted by my side and full consent was given in due time.

Standard A1.4 – Recruitment and placement

(b) require that no fees or other charges for seafarer recruitment or placement or for providing
employment to seafarers are borne directly or indirectly, in whole or in part, by the seafarer, other than
PAGE: OF:
SMM
Forms and Check Lists 6 7
Document: Release:
F 03-03 Sign-On Form 19

the cost of the seafarer obtaining a national statutory medical certificate, the national seafarer’s book
and a passport or other similar personal travel documents, not including, however, the cost of visas,
which shall be borne by the shipowner.

Signature:

10. Documents

Type of document Applicable Document No. Valid until


Job Description [ ] yes [ ] no []
checked
Drug and Alcohol Policy [ ] yes [ ] no []
checked
There is any particular condition [ ] yes [ ] no []
applicable during the engagement checked
due to Company’s Policy regarding
strict Alcohol Policy onboard such
as ‘’Dry vessel’’
Copies of contract and other [ ] yes [ ] no []
relevant dox in data base checked
Evaluation reports uploaded in data [ ] yes [ ] no []
base checked
Debriefing Forms filled and [ ] yes [ ] no []
uploaded in data base checked
Complaining Form filled and [ ] yes [ ] no []
uploaded in data base checked
Health Declaration Form [ ] yes [ ] no []
checked
Daily Crew Temperature Check [ ] yes [ ] no []
Records checked
Pre - joining checklist(OSM) to be [ ] yes [ ] no []
complete and share with OSM and checked
uploaded in data base
Sea service operated by the RNA? [ ] yes [ ] no []
checked
Is the seafarer informed about the [ ] yes [ ] no []
crew complement/ vessel type & checked
name / Main & AUX engine / vessel
trade / flag state requirements /
company policies / company D & A
policy / company particulars?
Is the seafarer informed about the [ ] yes [ ] no []
crew complement on board of checked
joining vessel?
Is the seafarer familiarized with the [ ] yes [ ] no []
Online Manual? (applicable for checked
Reederei Nord B.V.)
PAGE: OF:
SMM
Forms and Check Lists 7 7
Document: Release:
F 03-03 Sign-On Form 19

Crew Certificate Matrix verified and [ ] yes [ ] no []


signed (applicable for Reederei checked
Nord B.V.)
Is the seafarer informed/explained [ ] yes [ ] no []
prior engagement about the main checked
terms of collective
agreement/individual contracts,
including full payment with all
bonuses applicable?
Car transportation advise to [ ] yes [ ] no []
Owners checked
PCR tests results at Otopeni airport [ ] yes [ ] no []
needed, not later than 8 hrs in checked
advance.COVID 19 traveling
restrictions, registration and
quarantine well known and briefed,
including on destination, port of
embarkation.
Saltgate Shipmanagement GmbH [ ] yes [ ] no []
Saltgate Shipmanagement(Cyprus) checked
LTD - DPP informed and received a
copy.
CBA of Company presented, Draft [ ] yes [ ] no []
of COE checked
MLC info -on board complaint [ ] yes [ ] no []
procedure checked

Date: 28.04.2025
Manning Agent: STARGATE CREWING AGENCY
Step 1 to 11 was checked by: Andrei Lipan
(Name of the Manning Agent’s Staff)
Signature:
Crew name: BODNARI ION Crew signature

You might also like