PERSONAL DETAILS

Position Applied for
Family Name (Surname)
Given Name (First name)
Date of Birth
Nationality
Height
Shoe size

CNP
Father's name
Place of birth
Sex(M/F)
Weight
Size

cm
cm

Photo

kg
S,M,L,XL,XXL

Marital Status

Address
Street
City/Country
Airport(s)
Next of Kin
Relationship
Address
Street
City/Country
Remarks
Dependent(s): (Name and Date of Birth)

Passport No.
Seaman's book No
USA Visa

Tel
Fax
Mobile
e-mail
Tel
Fax
Mobile
e-mail

NATIONAL DOCUMENTS
Issued on
Issued on
Issued on

Issued at
Issued at
Issued at

CERTIFICATE OF COMPETENCY
Issued on
Issued at
Issued on
Issued at

Type
Endorsement

ENGLISH

level = (poor, fair, good,very good,excellent)

FRENCH

level = (poor, fair, good,very good,excellent)

Valid till
Valid till
Valid till

Valid till
Valid till

OTHER FOREIGN LANGUAGES
COMPUTER LITERACY
Yes
If yes, give details of software used:

No

Issued on
Issued at
Valid till
NATIONAL ENDORSEMENTS RELATED TO SPECIAL TRAINING CERTIFICATES for TANKER VESSELS(A-V/1)
Specialized training for gas tankers
Issued on
Issued at
Valid till
Specialized training for chemical tankers
Issued on
Issued at
Valid till
Specialized training for oil tankers
Issued on
Issued at
Valid till
Tanker Familiarization
Issued on
Issued at
Valid till
Issued on
Issued at
Valid till
Issued on
Issued at
Valid till
Romanian National Medical
Yellow Fever
Hepa-B
Epidemic Cert
D+A Pre-Joining test
Chem. Tanker Health
Flag
Medical
Application no.
Temporary license no.

Flag

Seaman's Book No.

MEDICAL and VACCINATIONS
Issued on
Issued on
Issued on
Issued on
Issued on
Issued on

Valid till
Valid till
Valid till
Valid till
Negative
Valid till

FLAG STATE DOCUMENTS( On hand or in-process)
Issued on
Issued at
Issued on
Issued at
Issued on
Issued at
Issued on
Issued at
FLAG STATE DOCUMENTS(On-Hand)
Issued
Competency
Issued
Endorsement
Valid
Type
no.
Valid Type

Positive

Valid till
Valid till
Valid till
Valid till

no.
Valid

GOC no.
Valid

tab A .2.ADDDITIONAL TRAINING Certificates Number Place issued Date Issued Risk Management and Incident Investigation Framo Others Others Others Others Page 2 of 3 Valid Until .1. tab A .VI/I p.1.3.1.VI/I -3 Personal Safety and Social 4 Responsibilities A .STCW CERTIFICATES 78/95 .1.VI/I -4 V .VI/I p.4. tab A .1.2.2.2.RATINGS Certificates Number Place issued Date Issued Valid Until Regulations Personal Survival 1 Techniques A .VI/I p.VI/I -1 Fire Prevention and Fire 2 Fighting A -VI/I p.VI/I -2 3 Emergency First Aid A .2. tab A .

8 to 14 A-V/1para.1 to 7 A-V/1.VI/4 Para 4-2 A-II/1. BI/12para.ISPS Code Sect A-13/2 11 12 13 14 15 16 Oil Tanker Familiarization Advanced Training on Oil Tanker OperationsTanker Familiarization Chemical Specialized Training for Chemical Tankers Liquefied Gas Tanker Familiarization Specialized Training for Liquefied Gas Tankers Operartional Use of Electronic Chart 17 Display and information System (ECDIS ) 18 Inert Gas Systems (IGS) Transport and Handling Dangerous 19 Hazardous and Harmful Cargoes 20 Ship Safety Officer 21 Personal Survival Techniques 22 Crude oil washing (COW) Personal Safety and Social Responsibilities 23 on board ships A-V/1para.12 A-VI/1 para 2.1 A-V/1para. to Sec. A-II/2. AIII/2 29 Washing of oil tankers cargo holds A-V/1para.15 to 21 A-V/1.OFFICERS Certificates Number Place issued Proficiency in Survival Craft and Rescue 1 Boats other than fast rescue boats 2 3 4 5 6 7 Date Issued Valid Until Regulations A .1 A-II/1.1.12 A-II/1. A-II/2 A .VI/2 Para 1 to 4 Fast Rescue Boats Advanced-Fire Fighting Medical Care Maritime English Radar Simulator A-VI/3 A .II/1.2 acc. To Sec.34 A-II/1.p.1.para. A-III/1.1. Bridge TeamWork and Search 8 and Rescue management level A-I/12 and A-II/2 9 Ship Safety Officer Ship Security Officer 10 SOLAS Ch XI/2.para.APPLICATION FORM STCW CERTIFICATES 78/95 . A-II/2 A-VI/5 A-VI/1 para 2.1 to 7 A-V/1para.2 acc. BI/12p. A-II/2 Prevention of Pollution of the Maritime 24 Environment 25 Ship Handling and Maneuvring Simulation 26 General Operator for GMDSS (GOC) 27 Bridge Team and Resource Management Tanker Management and self-assesement 28 A-II/1.2 to17 Radar Observer and Plotting Radar ARPA.1. 22.4 No expiry date A-II/1. A-II/6 A-IV/2 A-VIII/1 and A-VIII/2 TMSA-OCIMF/2004 Guide and ISM Code MARPOL-73/78 .1 to 7 A-V/1.

I understand that previuos employers may be asked for information concerning my employment record with them and I hereby release from all liability or damage those individuals or companies who provide such information.) I herewith certify that the above information is true and accurate to the best of my ability and that no certificate of competence or licence issued to me has ever been revoked or suspended. Signature: Date: Page 3 of 3 Owner Crew Agent Flag Built .VESSEL Position From Months PREVIOUS SEA SERVICE( please start with the latest ) To Reason Type Days GRT Engine KW Pls state the vessel where you have obtained experience on the following: Vetting Inspections/CDI : (specify companies) QA+ISM Experience: Cargoes Carried: References:(Pls state last 3 shipmanagement companies with tel no.