EMPLOYMENT APPLICATION FORM

Position applied Second choice

for
Date of
availability
Surname Name / s
Date / place of / minimum employment age 18 years
birth
Nationality Marital Sex
status
CONTACT INFORMATION NEXT OF KIN DETAILS

Home address Relationship

Phone Name
E-mail NOK address
Nearest airport NOK contact
PERSONEL DETAILS & UNIFORM

Hair color Weight (kilograms)

Eye color Working clothes size
Height (centimeters) Shoes size

EDUCATION

Name of school or academy Department From To

PASSPORTS, SEAMANS BOOKS , VISAS

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

issue
National Passport
National Seamans Book
Seamans Passport (if
applicable)
US C1/D visa

MEDICAL AND VACCINATIONS

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

Seafarers Medical
Yellow Fever vaccination

Issue 1 Revision 0 GOOD WINDS MARINE SERVICES SRL

Date: Dec 2012 Bd Mamaia, no 158, 2nd Floor, Room 2, Constanta,
Crewing Form 2.1 900575
Tel/Fax: +40 241 582 955 , e-mail:
office@goodwinds.ro
Page 1 of 2
 EMPLOYMENT APPLICATION FORM
CERTIFICATES (STCW A II/1-4 & A III/1-4)

Name of document Capacity Number Place of issue Issued Expire

Certificate of
competency
Endorsement
GMDSS

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

Name of document Number Place of Date of Date of
issue issue expiry
Basic First Aid
Basic Fire Fighting
Advanced Fire Fighting
Personal Survival Techniques
Personal Safety and Social
Responsibility
Medical First Aid
Medical Care Person in Charge
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)

SSO Endorsement
HAZMAT (Acc US CFR)
Maritime English
MARPOL
SEA SERVICE DURING THE LAST FIVE YEARS
Year Engine
Name of
Rank Company Built Flag Type GRT type From To
vessel
KW

Issue 1 Revision 0 GOOD WINDS MARINE SERVICES SRL

Date: Dec 2012 Bd Mamaia, no 158, 2nd Floor, Room 2, Constanta,
Crewing Form 2.1 900575
Tel/Fax: +40 241 582 955 , e-mail:
office@goodwinds.ro
Page 2 of 2
 EMPLOYMENT APPLICATION FORM


REFERENCES
Name of
Company Contact Tel Fax Email
vessel


OTHER QUALIFICATIONS AND SHORE BASED EMPLOYMENT

ENGLISH LANGUAGE COMPUTER
KNOWLEDGE
Marlins Test in %
If other test state details

Issue 1 Revision 0 GOOD WINDS MARINE SERVICES SRL

Date: Dec 2012 Bd Mamaia, no 158, 2nd Floor, Room 2, Constanta,
Crewing Form 2.1 900575
Tel/Fax: +40 241 582 955 , e-mail:
office@goodwinds.ro
Page 3 of 2