Magmaris Ltd.

F-005/01.13.

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Office Use Only
Ref. No.
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Offshore, Crewing, Shipping & Consulting Agency

Ivana Gundulia 41, 22000 ibenik, Croatia
tel: + 385 22 340 476 ;Fax: + 385 22 340 491;
e-mail: crewing@magmaris.net

Please complete this form in black ink or type

1. CONTACT DETAILS (Enter details)

RANK

Country of Residence

DEPARTMENT
(Deck/Engineer)

Availability /expected
wages

Title

Date and place of Birth

First Name

Nationality

Surname

Tel No 1

Address

Tel No 2

Height (CM)

E mail

Waist (Inch)

Nearest Airport

Weight (Kg)

Skype ID

Shoe size/ Overall size

2. NEXT OF KIN DETAILS

T-Shirt size/ Cargo Pant Size

(Enter details)

NOK Name

NOK Address

NOK Tel No
NOK Relationship
3. CERTIFICATE OF COMPETENCY (Latest only)
Details

No. Cert.

4. CERTIFICATE CHECK LIST

Details

Issue Date

Expiry Date

Place of Issue

(Enter details)

Issue Date Expiry Date

No. Certificate

Place of Issue

Passport
Seamans Book National
Seamans Book Internat.
USA VISA
VISA
5. STCW CERTIFICATES
Issue Date Expiry Date
Basic training
Advanced Fire Fighting
Medical Care
Medical First Aid
Proficiency in survival
craft and rescue boat
Navigation, Radar &
ARPA Simulator
Tanker Familiarization
ECDIS

No. Certificate

Place of Issue

Magmaris Ltd.

F-005/01.13.

GMDSS
Ship Handling Simulator
BOSIET
ITSO
HUET
DP system
maintenance

6. SEA SERVICE (Previous Sea Experience Earliest Date First)

Company

Rank

Vessel
Name

Vessel
type

Flag

GRT

DWT

Engine
Type

KW

Signed on

Signed off

Reason for
discharg

I confirm that the details given are to the best of my knowledge accurate and true, that I am in legal possession of the
above qualifications and certificates. I also agree that my personal details can be used by Magmaris ltd for
employment purposes.

Signiture :

Date: