Application form Diverso Impex

Maritime education center and crewing agency

Personal Information
Surname, Given name
Rank applied for
Nationality
Father's name
Mother's name
Marital status
OIB
Date of birth
Place of birth
Present address
Mobile phone (cellphone)
Telephone (landline)
E-mail
Nearest airport
Height in cm
Weight
Next of kin
Next of kin address
Education (school/college)
Previous salary
Expected salary

Please send filled Application form to e-mail address: diverso@diversoimpex.hr

Application form Diverso Impex

Maritime education center and crewing agency

Passport
Number

Place issued

Date issued

Seaman's book
Country

Number

Place of issue Date of issue

Date of
expiry

Certificate of Competency (CoC)

Country

Grade of
license

Number

Place of
issue

Date of
issue

Date of
expiry

Number

Place of
issue

Date of
issue

Date of
expiry

Certificates STCW
Country

License

Medical
Medical exam
D&A test
CB test
Yellow fever

Date of issue

Date of expiry

Please send filled Application form to e-mail address: diverso@diversoimpex.hr

Application form Diverso Impex

Maritime education center and crewing agency

Experience (in last 5 years or last 10 ships served)

Ship name

Engine*

Power*

Trade **

DWT**

Type
of
vessel

Company

Flag

Rank

From
dd.mm.yy
yy

* For Engine officers

** For Deck officers

_________________________
Date
www.diversoimpex.hr
Tel: +385 21 453 040

_________________________
Signature
DIVERSO IMPEX
d.o.o.
Velebitska 123
21 000 Split
Croatia

diverso@diversoimpex.hr
Fax: +385 21 453 048

Please send filled Application form to e-mail address: diverso@diversoimpex.hr

To
dd.mm.yy
yy