Please complete addresses of your previous employers for references

APPLICATION FORM

POSITION APPLIED FOR: _______________

Personal data

Family Name:	Name :	Father's name:
Date of birth:	Place of birth:	Nationality:
Marital status:	Children (name & DOB):
Address :	Tel (including city code):	Mobile;
Next of kin and relationship: .-father,.-mather
Next of kin’s address :	Tel:
Inter. P’port No:	Issued:	Valid:	Place of issue:
Seaman's book No:	Issued:	Valid:	Place of issue:
Civil P’port No:	Place of issue:	Date of issue:
USA visa No:	Issued:	Valid:	Place of issue:

Medical information

Medical examination	Issued:	Valid:	Weight, kg:	Height, cm:
Drug & alcohol test	Issued:	Valid:	Eyes:	Hair:
Yellow fever	Issued:	Valid:	Overall size:	Safety shoes:

Name of marine school attended	Address of school	From	To	Degree of diploma

National License

Certificate of competency hold	Number	Issued	Valid	Place of issue
Диплом
Endorsement

IMO	STCW Certificates	Number	Issued	Valid	Place of issue
	GMDSS Endorsement
	Carriage of dangerous and hazardous substances
1.08	ARPA (A-I/12, A-II/1, A-II/2, B-I/12)
	Personal safety (A-VI/1) (IMO 1.13, 1.19, 1.20, 1.21)
2.03	Advanced fire fighting (A-VI/3)
1.23	Prof. in survival craft (A-VI/2 p.1-4)
1.14	Medical first aid (A-VI/4-1)
1.15	Medical care (A-VI/4-2)
	Hazardous cargoes (B-V/4, B-V/5)
	Safety officer (ISM code)
	Crowd management (A-V/3)
	Bridge Team Management
	Training for person. serving onpassenger ships other than RO-RO pas.ships
	RoRo passenger (A-V/2-1,-2,-3,-4,-5)
	Ship security officer
	Ship handling arrangements
	Свид-ство о повышении квалификации

Dangerous cargoes certificates

1.01	Oil tank. familiarization (A-V/1)
1.02	Oil tank.Specialized training (A-V/1,p.9-14)
1.03	Chem. tank. familiarization (V/1)	.
1.04	Chem. tank. advanced (A-V/1,p.16-21)
1.05	LPG familiarization (V/1)
1.06	LPG advanced (A-V/1,p.23-34)

PREVIOUS SEA SERVICES (last 5 years)

Name of vessel	Year of built	Company	Flag	Type of vessel	DWT	Type of main engine	BHP	Rank	From Day,mont,year	To Day,month,year

Another States Seamen’s Books	Rank	Document No	Issued	Valid	Another States Certificates of competency	Rank	Document No	Issued	Valid
Liberia					Liberia
Panama					Panama

Please complete addresses of your previous employers for references

Company	«»	Tel:	Company		Tel:
Address		Address

Signature____________________ Date ________________ I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.