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CMA SHIPS REF: CREW/FORM/01 TITLE

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CREWING MANUAL VERSION: 02/08/2010
APPLICATION FORM

APPENDIX 2 PAGE 1 of 1

APPLICATION FORM
ATTACH CMA Ships ROMANIA 2nd Floor, 13-15 Mamaia Boulevard, CONSTANTA C.P. 900697 Tel: +40 241610778 / +40 241610779 E-mail: cnz.crew@cmaships.com

Position applied for: Type of vessel: Availabibity date:

Are you responding to a media advertisement? If YES, please state which one Are you applying upon personal or professional recommendation? If YES, please state who Surname: Other names Place of birth: Known as Date of Birth:

YES/NO

YES/NO

First name: Nationality: Age: Male Female

Passport
Number Place of issue Date of issue Date of expiry Issuing Authority

Visas
Type C1/D (USA) C1 (USA) D (USA) Australia Entry visa MCV (Australia) Schengen Number Place of issue Date of issue Date of expiry

Education Background
School / College From To Highest qualification attained

Personal details
Full address: Postal code: E-mail: Home tel number: Mobile phone: Domestic Airport Marital status: International Airport Country:

Full name of Next of Kin: Address of Next of Kin if different from above Phone if different from above

Relationship

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Dependents Name Date of birth Age Gender Relationship Person to contact in case of emergency Name: Address: Phone number: Mobile number: Relationship National Seaman's Book Number Place of issue Date of issue Date of expiry Issuing Authority National Certificate of Competency (COC).Licences Grade Issuing Authority Number Date of issue Date of expiry Place of Issue Date revalidated Date expiry National GMDSS & Endorsement Issuing Authority Number Date of issue Date of expiry Place of Issue Medical Fitness Certificate Type Date of issue Date of Expiry Yellow Fever Vaccination Date of Issue Date of Expiry Foreign languages other than English Language Level: Beginner Intermediate Advanced Medical History Have you ever signed off from a ship due to medical reasons? Name of vessel Yes / No Date of Occurrence If yes give details Brief description of Illness or Injury Other personal details Height: Colour of eyes: Uniform Shirt size: Weight: Safety shoes size: Uniform Trousers size: Colour of Hair: Boiler suit size: 2/7 .

3 STCW Reg A-VI/3 STCW Reg A-VI/4-1 STCW Reg A-VI/4-2 par 2 STCW Reg II/2 STCW Reg II/1 Advanced Fire Fighting Medical First Aid Medical Care ROP ARPA / NCC Radar Simulator ECDIS HAZ MAT Ship simulator bridge teamwork BTM / ETM Ship Security Officer (SSO) BASSnet Ship handling & manoeuvring Bridge resource management Loading software (name it) Large Vessel Handling Simulator / Engine Room Simulator 1.15 1.27 STCW Reg II/1 par.13 1.07 Proficiency in survival craft & Rescue Boats STCW Reg A-VI/2 par 1.23 2.Details of other Marine courses Type of Marine Course Basic Training Personal Survival Techniques Basic Fire Fighting Elementary First Aid Personal Safety & Social Responsibilities (Human Relationship) IMO model course 1.415 CMA CGM Indos Number Upgradation Course Revalidation Course for renewal of CoC High Voltage Training Reefer Training Engine Maker’s Training Crane Manufactures training Vessel security training course Ship Safety Officer ISF Marlins English test MARPOL ISPS code IMO Assembly Res A741(18) UK MCA 3/7 .204 1.22 STCW Reg II/1 STCW Reg VI/5 / ISPS Code STCW Reg II/1 & II/2 STCW Reg VIII/2 US33CFR 157.20 1.700-172.19 1.1.20 1.2.13 1. A-VI/1-1 STCW Reg A-VI/1-2 STCW Reg A-VI/1-3 STCW Reg A-VI/1-4 A- Number Date of issue Date of expiry BASIC TRAINING 1.14 1.Regulation STCW Reg. VI/1-1 to A-VI/1-4 STCW Reg.5 US 49 CFR 172.19 .03 1.21 Reference.21 1.08 1.

Of Recognition of the National CoC Bahamas: Endorsement of the CoC Endorsement of the GMDSS Seafarer's Identification and Record Book United Kingdom: Endorsement of the CoC (UK CeC) Endorsement of the GMDSS Seafarer's Identification and Record Book Panama: Endorsement of the CoC Endorsement of the GMDSS GOC Seafarer's Identification and Record Book Other ( pls specify) 4/7 .Flag State Documents Document Grade Number Place of Issue Date of Issue Date Expiry Malta: Seafarer's Book Endorsement of the GMDSS Endorsement of the CoC Cyprus : Seafarer's ID and Sea Service Record Book Cert.

BC = Bulk Carrier. LNG = Tanker. GC = General Cargo. EOC = End of Contract 5/7 . LPG = Tanker. VS = Vessel Sold.Employment history (at least the last 5 years) Vessel * Company Manning Agent Trading area Vesse l type Flag DWT / TEU Year built Main Engine Make Type KW Position Sign on date Sign off date Total mm/dd ** Reaso n for leaving *** * or industry sector if ashore ** Use abbreviation: PC = Pure container. Chem = Chemical. RoRo = Roll on Roll off *** Use abbreviation: MR = Medical Reason.

3/E 3/O .C/E C/O .4/E E/O Total Years as/ on C/E 2/E 3/E 4/E E/O Total SEMT Pielstick Steam Turbine Container Tanker Bulk carrier Roro others (Please state) Sulzer RTA Sulzer RND B&W MAN others References Do you have any objection if we will contact your last employers for reference? If YES please specify why: If NO please specify below: Yes/No Please give the name and address of your current or immediate past employer Name of company Name of person to contact Address Tel number Please list two contactable referees or past employers Name of company Name of person to contact Address Tel number Name of company Name of person to contact Address Tel number 6/7 .2/E 2/O .Summary of Experiences (in number of years) Years as/ on Master .

that no Certificate of Competency or License issued to me has ever been revoked or suspended. I also certify that my medical history contained abocve is true and any false statement or undisclosed material information about past illness or injury will disqualify me from any employment benefits and claims. 7/7 . further. Date________________ Signature_______________________ * The company may contact my previous employer for references.Bank details Bank name: Branch name Address: Account name/ Title Account number: Swift name IBAN number: Sort code: I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief.