S/N

APPLICATION FOR

PERSONAL DATA
POSITION(s)/ RANK - APPLIED
FAMILY NAME, GIVEN NAME
DATE OF BIRTH (dd/mm/yyyy)
PRESENT ADDRESS
MARITAL STATUS

HEIGHT

WEIGHT

ENGLISH LEVEL

PERSONAL DOCUMENTS
PASSPORT

SEAMAN S BOOK

NUMBER

DA

NUMBER

DA

NATIONAL
FLAG SEMANS BOOK

LICENCE

NUMBER

GRADE

NATIONAL

FLAG LICENCE (NAME Flag)

OTHER CERTS.
Basic Safety and instruction
Radar Observer A-II/1
ARPA A-II/1
GMDSS A-IV/2
STCW Proficiency in Survival Craft and
Rescue boat A VI/2-1
STCW Advanced Fire-Fighting
A-VI/3
STCW Take Charge of Medical Care Aboard
Ship A VI/4-2

NUMBER

DATE OF ISSUE

Certificate for Handling and Stowage at the

operational and management levels A-II/1 and
A-II/ 2
Bridge Team Management
STCW Fast Rescue Boats A-VI/2-2
SSO ISPS Code, Part A-12,
Part B-13, (Approved by Flag)
USA VISA
Maritime Australia VISA

SERVICE RECORDS LAST FIVE YEARS

RANK / POS

NAME OF VESSEL

TYPE

DWT / HP

ENG-TYPE

REMARKS Contact number previous Companies service:

Name Company

Phone Number

Application Date:
//

APPLICATION FORM

PHOTO

CITIZENSHIP

TEL.NO.

NEXT OF KIN

GRADE

DATE OF ISSUE

DATE / PLACE OF ISSUE

EXPIRY DATE

DATE / PLACE OF ISSUE

EXPIRY DATE

DATE / PLACE OF ISSUE

ENDORSED TILL

PLACE OF ISSUE

EXPIRY DATE

ENG-TYPE

Phone Number

FROM

TILL

COMPANY

Fax Number