Application Form s26

Lireweg 14 T. +31(0)88 55 70 101 2153 PH Nieuw-Vennep F. +31(0)88 55 70 150 P.O. Box 3036 Email: [email protected] 2130 KA Hoofddorp, The Netherlands APPLICATION FORM Position: Availability: Last name: Requested sailing time: First Name: Citizenship: Date and Place of Birth: Phone: Street & Nr.: Mobile: Postal (zip) code: E-mail: Your picture here City: Country: Address, Next of kin: phone: Relation: Education: Nearest Airport: English level:

DOCUMENTS Number: Passport: Issued: Valid: Seaman’s book (national): Issued: Valid: Cert. of competency (national): Grade: Issued: Valid: Endorsement (national): Grade: Issued: Valid: GMDSS: Issued: Valid: GMDSS endorsement: Issued: Valid: Cert. of competency (Dutch): Grade: Issued: Valid: Seaman’s book (Dutch): Issued: Valid: Seaman’s book (flagstate): Country: Issued: Valid: Cert. of competency (flagstate): Grade: Issued: Valid: TRAVEL DOCUMENTS Number: Us visa (C1D): Issued: Valid: Schengen MEV visa: Issued: Valid: CERTIFICATES Basic Safety Training & Instruction: Issued: Valid: Prof. in Survival Craft and rescue boats: Issued: Valid: Fire Prevention & Fire Fighting: Issued: Valid: Medical First Aid: Issued: Valid: Advanced Fire Fighting: Issued: Valid: Medical Care: Issued: Valid: Radar Navigation Operational level: Issued: Valid: Radar Navigation Management level: Issued: Valid: Ship Security Officer: Issued: Valid: ECDIS: Issued: Valid: Tanker Familiarisation: Issued: Valid: Oil tanker specialized: Issued: Valid: Chemical tanker specialized: Issued: Valid: Liquefied Gas Tanker Specialized: Issued: Valid: Bridge Team and Resource Management: Issued: Valid: Engine Team and Resourse Management: Issued: Valid:

- page 1 of 2 -

THE LATEST SEA SERVICE Vessel Flag Vessel’s type Main engine type / KW DWT Signed on Signed off Total days Rank Ship owner

SUMMARY OF SAILING MONTHS IN RANK RANK: RO/RO Product: Chemical: LPG: Heavy Lift: Cargo: Container: Bulk: Multi-purpose: Total: :

TOTAL NUMBER OF MONTHS: REMARKS

- page 2 of 2 -