Application Form

Position applied for

Position        Second choice   
Wage (min, $)   

Personal Information

Full Name     
Date of birth Country of birth
Home address:
Phones:
English language knowledge:
E-Mail    
US visa Exp.
Australian visa Exp.

Records of Service for last seven years

Ship's name Year of built Type DWT Main Engine Type Country (Flag) Owner/ Manager Position Period from (d/m/y) Till (d/m/y)

Technical Information

Ship's name Type of cranes Number Tonnage

Contact details of previous Employers

Name of Ship

Crewing Agency / Shipowner Tel. numbers / Address Person in charge

Additional Information

Marital status
Children under the age of 18 -
Next of kin
Color of hair
Color of eyes
Height
Weight
Boiler suite size
Safety shoes size

List of Documents

Identification Code #
National Passport # Issued
By
Tourist Passport # Issued exp
Seaman's Passport AB # dtd exp
Other Countries Seaman's Book :
Country # dtd exp
Education
from (d/m/y)       till (d/m/y)

Certificates

Competency : Grade # dtd exp
Endorsement # dtd exp
STCW'78/95 A-VI/1 (personal survival, fire prevention, elementary first aid & social responsibilities) # dtd exp
Proficiency in survival craft # dtd exp
Advanced fire fighting # dtd exp
Ship's medical care # dtd exp
Electrical familiarisation / Electronics for marine engineers # dtd exp
Ship's security officer # dtd exp
Hazmat # dtd exp
Others:  # dtd exp
Others: # dtd exp
Others: # dtd exp

Medical examination and vaccination

Yellow Fever issue date
Last medical examination issue date

Remarks