Seaman Book S and Licenses Issued by Other Countries

39/1, Uspenskaya Str., Odessa, Ukraine V. Ships Offshore Phones: +38 048 7222085 Fax: +38 048 7222595 Ukraine www.vshipsoffshore.com

EMPLOYMENT APPLICATION FORM Rank: Date Available for Joining: Vessel:

Personal details Surname: First name: Other name: Date of birth: Place of birth: Nationality: Home address: Phones:

Nearest airport: Nearest international airport:

Documents

Passport No. Issued on: Expiry date: S/book No. Issued on: Expiry date: US visa C1/D Issued on: Expiry date:

LICENCE PARTICULARS MOT Grade Cert No Place of Issue Date of Issue Expiry date National License Endorsement Tanker endorsement Crude Oil Liquid chemical Liquefied gas

CERTIFICATES Cert No Date of Issue Expiry date Basic Safety Training Medical First Aid Advanced Fire Fighting Proficiency In Survival Craft ROP/ARPA G.M.D.S.S. Ship Security Officer Ship Safety Officer Dangerous And Hazardous Substances Yellow fever US VISA B1 DP induction course HUET ECDIS Medical Fitness Certificate Bridge Team Management Seaman Book’s and Licenses issued by other countries Type Issuing Country Cert No Date of Issue Expiry date

Pre-SEA Training / Nautical School / Maritime School Qualifications Passed:

SEA SERVICE Period of Service Year Type of Vessel Name of Vessel Flag DWT and HP Rank Name of Owners Built and Engine (Type) dd/mm/ dd/mm/ yyyy/ yyyy/

References : Interview date: Interviewed by: Name of company: Level of English: Appearance: Attitude:  No. Name of company: Experience with Multinational Crew: Yes  No  Duration (Months): 12  No. Nationalities:

Next of kin Personal data: Name/Relationship Weight, kg: Height, cm: Home address: Eyes: Hair: Phones: Overall size: Safety shoes:

Names of Children: Date of Birth: Comments: