Date Available for Appointment

Application Form and Doc No: Marine HR TKG - 51 Record of Personal Information and Past Valid From: 28/06/2005 Experience Version: 1 Author: John Williams

Please complete the attached form by hand or electronically (you can type directly in the fields provided). Please send the completed application to the applicable one of our global addresses. [email protected] [email protected] [email protected]

DATE AVAILABLE FOR APPOINTMENT: Present rank: Rank applied for: Date: Name in full (First, Middle, Last) Nationality Photo

Date of birth Age Married / Single / Divorced / Widower Place of birth Next of kin Permanent / Contact address Name Relationship Address

(include international dialing code) Telephone number Mobile number Fax number Email address

Nearest airport Colour of hair / eyes Height Weight /

If accepted, date available for service: U.S. Visa Type Valid until

Medical certificate expiry date: Other Visa Type Valid until

Yellow fever vaccination expiry date: Other Visa Type Valid until

Professional Qualifications Licences Grade of Licence Number Date Place Expiry licence Type issued issued / Date (Steam Revalidate or Motor) d National (please state)

Bahamian

Liberian Application Form and Doc No: Marine HR TKG - 51 Record of Personal Information and Past Valid From: 28/06/2005 Experience Version: 1 Author: John Williams

Panamanian

Seaman’s book Place & Expiry date Passport Place & Expiry number / date nationality date date Nationality issued / Number issued

Referees: 1) 2) Name, company and contact telephone number

Other professional qualifications / Certificates / Endorsements held Course / Certificate Place held Date held Date of expiry

Signature: Application Form and Doc No: Marine HR TKG - 51 Record of Personal Information and Past Experience Valid From: 28/06/2005 Version: 1 Author: John Williams

Previous Sea Experience

Vessel name Containment Deck: Trading area / Vessel Type Steam or Full Rank Period Months /Days Type e.g. Deadweight e.g. Motor Company From – To (No.96;MKIII; LNG/OIL/LPG name IHISPB;Moss) Engine: Type & BHP Please state one (S or M) only Last /

2nd Last /

3rd Last /

4th Last /

5th Last /

6th Last /

7th Last /

8th Last /

9th Last /

Application Form and Doc No: Marine HR TKG - 51 Record of Personal Information and Past Experience Valid From: 28/06/2005 Version: 1 Author: John Williams

10th Last /

11th Last /

12th Last /

13th Last /

14th Last /

15th Last /

Other experiences (New buildings / Dry docks / Repair yards / Office secondments, etc. Application Form and Doc No: Marine HR TKG - 51 Record of Personal Information and Past Valid From: 28/06/2005 Experience Version: 1 Author: John Williams

Marine Course Attended Date Attended Expiry (if any) Remarks Merchant Navy Basic Fire Fighting (3 day) Merchant Navy Advanced Fire Fighting (4 day) Merchant Navy Fire Team Leader / Command & Control Basic Sea Survival Elementary First Aid (1 day) Medical First Aid (4 day) Proficiency in Medical Care Onboard Ship Certificate of Proficiency in Survival Craft Specialised Tanker Training (Oil) Specialised Tanker Training (Chemical) Specialised Tanker Training (Liquid Gas) Crude Oil Washing Inert Gas Plant Navigation, Radar & ARPA Sim Training (Operational Level) Navigation, Radar & ARPA Sim Training (Management Level) Electronic Chart Display & Information Systems Manned Model Shiphandling Shiphandling Simulator Course Engine room simulator Course Bridge Team Management Course Engine Team Management Course Crew Resource Management Course Crisis Management Management of Major Emergencies Personal Safety & Social Responsibilities Dangerous Goods by Sea (IMDG) Ship Safety Officer Ship Security Officer Efficient Deck Hand Train the Trainer Behavioural Safety Awareness Application Form and Doc No: Marine HR TKG - 51 Record of Personal Information and Past Valid From: 28/06/2005 Experience Version: 1 Author: John Williams

Safety Awareness / Accident Prevention Abrasive Wheel Regulations Welding Crowd Management Crisis Management & Human Behaviour Passenger Safety, Cargo Safety & Hull Integrity Fast Rescue Craft (Boatman) Fast Rescue Craft (Coxswain) Draughtercraft Coxswain Standby Vessel Advanced Medical Aid Standby Vessel Command & Control Standby Vessel - Initial Training for Shipboard operations Civil Aviation Authority Marine Operators Certificate Helicopter Underwater Escape Training Helideck Assistant Helicopter Landing Officer Offshore Emergency Helideck Team Member Dynamic Positioning (Basic) Dynamic Positioning (Advanced) Any other Relevant Training: