Quality Management System

EMPLOYMENT APPLICATION FORM

Issue 2 Revision 0 Date: Dec 2009 CRW 2.1 Page 1 of 3

EMPLOYMENT APPLICATION FORM

Position applied for Second choice Date of availability Surname Name / s Date / place of birth Nationality Marital status Home address Secondary address Home phone / FAX Mobile phone E-mail Nearest airport

ATTACH PHOTO

Sex CONTACT INFORMATION

PERSONEL DETAILS & UNIFORM INFOMATION Hair color Eye color Height (centimeters) Weight (kilograms) Working clothes size Shoes size NEXT OF KIN DETAILS Relationship (i.e. Wife, etc.) Surname Given name/s NOK address NOK contact number Age and gender of children (if applicable) PRE-SEA EDUCATION
Name of school or academy Department From To

ickmers Marine Agency Romania SRL Bd.Mamaia 158, 2nd Floor , 900575 Constanta Romania Tel. +40 241 545 514, Fax:+ 40 241 545 516, e-mail: crewing.ro@rickmers.com

Quality Management System

EMPLOYMENT APPLICATION FORM

Issue 2 Revision 0 Date: Dec 2009 CRW 2.1 Page 2 of 3

PASSPORTS, SEAMANS BOOKS AND VISAS

Name of document National Passport National Seamans Book Seamans Passport (if applicable) US C1/D visa Number Place of issue Date of issue Date of expiry

CERTIFICATES (STCW A II/1-4 & A III/1-4)

Name of document Certificate of competency Endorsement GMDSS Capacity Number Place of issue Date of issue Date of expiry

BASIC TRAINING (STCW A VI/1 & A VI/2-4) AND OTHER CERTIFICATES

Name of document Basic First Aid Basic Fire Fighting Personal Survival Techniques Personal Safety and Social Responsibility Medical First Aid Medical Care Person in Charge Advanced Fire Fighting Proficiency in Survival Craft Fast Rescue Boat A.R.P.A. Radar Observer Certificate ECDIS Certificate BRM IMO Model Course 1.22 Ships Security Officer (ISPS-A 13.2) HAZMAT (Acc US CFR) Number Place of issue Date of issue Date of expiry

MEDICAL AND VACCINATIONS

Name of document Number Place of issue Date of issue Date of expiry

Seafarers Medical
ickmers Marine Agency Romania SRL Bd.Mamaia 158, 2nd Floor , 900575 Constanta Romania Tel. +40 241 545 514, Fax:+ 40 241 545 516, e-mail: crewing.ro@rickmers.com

Quality Management System

EMPLOYMENT APPLICATION FORM Yellow Fever vaccination SEA SERVICE DURING THE LAST FIVE YEARS
Rank Company Name of vessel Year Built Flag Type GRT

Issue 2 Revision 0 Date: Dec 2009 CRW 2.1 Page 3 of 3

Engine type KW

From

To

REFERENCES
Company Contact Name of vessel Tel Fax Email

OTHER QUALIFICATIONS AND SHORE BASED EMPLOYMENT

ENGLISH LANGUAGE
Marlins Test in % If other test state details

COMPUTER KNOWLEDGE GENERAL QUESTIONS

Expected wages per month Duration of contract required Reason for leaving present employer Why did you choose Global Management

Remarks for Seafarer:

APPROVED by (as applicable)

Client:

Owner:

Tech:

REJECTED (if rejected please explain the reasons)

Controlled copy
ickmers Marine Agency Romania SRL Bd.Mamaia 158, 2nd Floor , 900575 Constanta Romania Tel. +40 241 545 514, Fax:+ 40 241 545 516, e-mail: crewing.ro@rickmers.com

Quality Management System

EMPLOYMENT APPLICATION FORM

Issue 2 Revision 0 Date: Dec 2009 CRW 2.1 Page 4 of 3

ickmers Marine Agency Romania SRL Bd.Mamaia 158, 2nd Floor , 900575 Constanta Romania Tel. +40 241 545 514, Fax:+ 40 241 545 516, e-mail: crewing.ro@rickmers.com