Application Form

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, , , . 2297-VI 01.06.2010 . .

* .

(*) Required Fields

Position Applied for

Position: * Second Choice:
Other:
Wage (min, $):

Personal Information

First Name: *
Middle Name:
Last Name: *
Date of Birth:
Country of Birth:
Home Address:
Phone:
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 GRT Country (Flag) Owner/Manager Position Period from (d/m/y) till (d/m/y)

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:
Radar Observation & Plotting: dtd: exp:
Automatic Radar Plotting Aids: dtd: exp:
GMDSS: 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

Additional Information:
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