APPLICATION FORM
Position Applied for: _ _
Surname: Nationality: Given Name: Expected Salary (Min): Date of Birth: Date of Availability: CONTACT DETAILS Home Phone: Home address: Mobile Phone: Skype: E-mail: Other: VALID VISAS
Type of Visa and No. Place of Issue Date of Issue Valid Until
USA Visa Schengen Visa Other
SEAMAN 'S BOOK \ TRAVEL PASSPORT (Indicate if Biometric)
No: Place of Issue Date of Issue Valid Until
CERTIFICATE OF COMPETENCY
Type Of Document Grade No: Place of Issue Date of Issue Date of Expiry License Endorsement STCW CERTIFICATES
Type of Documents Reg. No: Place of Issue Date of Issue Date of Expiry Basic safety training STCW’ 78/95 A-VI/1 Advanced Fire Fighting A-VI/3 Proficiency in Survival Craft A-VI/2 Medical First Aid A-VI/4-1 Security Awareness Training A-VI/6-1 Designated Security Duties A-VI/6-2 Medical Care A-VI/4 HAZMAT / Dangerous Cargoes B-V/b,c Ship’s Safety Officer ISM Code Ship’s Security Officer ISPS Code Electrical and Electronic Equip. A-III/2
30b Mykhaylivska Str. Kherson 73000 Ukraine. Tel. +38 0552 460802, 398330. E-mail: [email protected] Ship Handling Arrangements A-II/1, 2 Leadership & Teamworking Tanker Familiarization A-V/1 Oil Tanker Training A-V/1 Chem. Tanker Training A-V/1 Inert Gas System MARPOL C.O.W. MARPOL Radar Navigation A-I/11,12,A-II/2,3 GMDSS IV/2 GMDSS Endorsement IV/2 Bridge Team A-II/1,2, B-VIII/2 Large Ship’s Handling ECDIS A-II/1, 2 Engine Room Resource Manag. A-III/1-3,VIII/2 DP Basic DP Advanced Full DP DP Maintenance BOSIET OPITO HUET OPITO Drug&Alcohol Test Medical Examination Vaccination Yellow Fever SEA SERVICE (at fleet during last five years) Rank From Till Vessel Name Vessel DWT Shipowner ME Type/BHP Flag Type
English Level: PERSONAL PARTICULARS Height: Eyes Color: Weight: Hair Color: Shoes: Overall: ADDITIONAL DETAILS Marital status/Children: Next of Kin &Relation: Next of Kin Address: Next of Kin Contact Phone:
DATE: Signature:
30b Mykhaylivska Str. Kherson 73000 Ukraine. Tel. +38 0552 460802, 398330. E-mail: [email protected]