CMA SHIPS Singapore OPERATIONS MANUAL SECTION 3

Ref: Crew/Form/01a Version: 01/07/2015 PAGE 1 of 1

TITLE: APPLICATION FORM

APPLICATION FORM ATTACH

RECENT
PHOTO

CMA Ships ROMANIA

13th Alexandru Puskin Street, CONSTANTA C.P. 900664
Tel: +40 241610778 / +40 241610779 E-mail: cnz.application@cmaships.com
Personal data operator no.19478

Chief
Position applied for:
Engineer
Type of vessel: Container
Availabibity date:midle August Midle August
2017 2017

Are you responding to a media advertisement? YES/NO

If YES, please state which one

Are you applying upon personal or professional recommendation? YES/NO

If YES, please state who

Surname: Strelciuc First name: Dan Sergiu

Other names Known as Nationality: Romanian

Place of birth: Fetesti Date of Birth: 26.11.1969 Age:47 Male

Passport
Date
Number Place of issue of Date of expiry Issuing Authority
issue
10.10.
55309381 Constanta 10.10.2020 Constanta Police
2015

Visas
Type Number Place of issue Date of issue Date of expiry
C1/D (USA) 2.013302E+13 Bucharest 30.10.2013 28.10.2018
C1 (USA)
D (USA)
Australia Entry visa
MCV (Australia)
Schengen

Education Background
School / College From To Highest qualification attained
Maritime University 1990 1995 Chief Engineer

Personal details
Full address:
Str Lyon no.31 Bl.A8 Constanta

Postal code: 900002 Country: Romania

E-mail: danstrelciuc@yahoo.com

Home tel number: 40241540770

Mobile phone: 40720857667

Domestic Airport Kogalniceanu International Airport Henri Coanda

Marital status: Married

1/9
Full name of Next of Kin: Strelciuc Aura Relationship Wife
Address of Next of Kin
if different from above
Phone
40723396901
if different from above

2/9
Dependents
Name Date of birth Age Gender Relationship

Strelciuc Sergiu Mihai 28.06.2003 14 Male Son

Person to contact in case of emergency

Name: Strelciuc Aura Relationship Wife

Address: Str.Lyon no.31

Phone number: 40723396901 Mobile number: 40723396901

National Seaman's Book

Date
Number Place of issue of Date of expiry Issuing Authority
issue
10.11.
12885CT Constanta 09.01.2018 RNA
16

National Certificate of Competency (COC)- Licences

Date
Issuing
Grade Number of Date of expiry Place of Issue Date revalidated Date expiry
Authority
issue
Chief Engineer RNA 68647 08.11.0 07.05.19 Constanta 10.11.2016 07.05.2019

National GMDSS & Endorsement

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

Medical Fitness Certificate

Type Date of issue Date of Expiry
Periodical 23.12.2016 23.12.2019

Yellow Fever Vaccination

Date of Issue Date of Expiry
03.11.2015 03.11.2025

Foreign languages other than English

Level: Begin
Language ner Intermediate Advanced

Medical History
Have you ever signed off from
No If yes give details
a ship due to medical reasons?
Name of vessel Date of Occurrence

Brief description of Illness or Injury

Other personal details

Height: 187 Weight: 89 Colour of Hair: Brown

Colour of eyes: Blue Safety shoes size: 46 Boiler suit size: 54

Uniform Shirt size:XXL Uniform Trousers size: XXL

3/9
Details of other Marine courses
IMO model
Type of Marine Course Reference- Regulation Number Date of issue Date of expiry
course
1.19 - 1.20 1.13 - STCW Reg.
Basic Training 1.21 A-VI/1-1 to A- 10776 27.04.2016 27.04.2021
VI/1-4
Personal Survival STCW Reg. A-VI/1-1
1.19 4922 14.05.2014 14.05.2019
Techniques

BASIC TRAINING
STCW Reg A-VI/1-2
Basic Fire Fighting 1.20 10776 27.04.2016 27.04.2021

STCW Reg A-VI/1-3

Elementary First Aid 1.13 10776 27.04.2016 27.04.2021

Personal Safety & Social STCW Reg A-VI/1-4

Responsibilities (Human 1.21 5820 19.09.2014 19.09.2019
Relationship)

Proficiency in survival craft & Rescue STCW Reg A-VI/2 par

Boats
1.23 8331 16.05.2014 16.05.2019
1.3
STCW Reg A-VI/3
Advanced Fire Fighting 2.03 5171 07.05.2014 07.05.2019

STCW Reg A-VI/4-1

Medical First Aid 1.14 4966 23.09.2014 23.09.2019

STCW Reg A-VI/4-2

Medical Care 1.15 6380 10.10.2016 Unlimited
par 2
STCW Reg II/2
ROP 1.08

STCW Reg II/1

ARPA / NCC 1.07

Radar Simulator

STCW Reg II/1

ECDIS 1.27
par.2.5
US 49 CFR 172.700-
HAZ MAT
172.204
STCW
Ship simulator bridge teamwork 1.22
Reg
II/1
BTM / ETM

STCW Reg VI/5 /

Ship Security Officer (SSO) 4842 16.09.2014 Unlimited
ISPS Code

BASSnet

STCW Reg II/1 & II/2

Ship handling & manoeuvring

STCW Reg VIII/2

Bridge resource management
US33CFR 157.415

Loading software (name it)

Large Vessel Handling Simulator / CMA CGM

Engine Room Simulator

Indos Number

Upgradation Course

Revalidation Course for renewal of CoC

High Voltage Training

Reefer Training

PrimeServ
Engine Maker’s Training MAN MC 30.03.2012

Crane Manufactures training

ISPS
Vessel security training course
code
IMO Assembly Res
Ship Safety Officer
A741(18)
UK MCA
ISF Marlins English test

4/9
Flag State Documents
Document Grade Number Place of Issue Date of Issue Date Expiry

Malta:

5/9
Employment history (at least the last 5 years)

Vessel * Company Manning Agent Trading area Vesse Flag DWT / Year Main Engine Position Sign on Sign off Total Reaso
l type TEU built date date mm/dd n for
** Make Type KW
leaving
***
MAN B&W 7L70MC-C
Arica NSC Shipping Stargate Worlwide PC Liberia 35358/28 2006 22890 C/E 17/02/2017 7/6/2017 EOC

MAN B&W 7K90MC-C

HS Bruckner Hansa Shipping Stargate Worlwide PC Liberia 42004/35 2009 32009 C/E 16.05.201620.09.2016 EOC

MAN B&W 8K80MC-C

HS Onore Hansa Shipping Stargate Worlwide PC Liberia 38608/26 2006 28892 C/E 22.11.2015 12.04.2016 EOC

HS Shackleton Hansa Shipping Stargate Worlwide PC Malta 58070/48 2013 MAN B&W 6S80ME- 26070 C/E 25.05.201508.10.2015 EOC

HS Onore Hansa Shipping Stargate Worlwide PC Liberia 38608/26 2006 MAN B&W 8K80MC- 28892 C/E 20.11.2014 21.03.2015 EOC

HS Oceano Hansa Shipping Stargate Worlwide PC Liberia 38608/26 2006 MAN B&W 8K80MC- 28892 C/E 21.05.201425.07.2014 EOC

HS Bach Hansa Shipping Stargate Worlwide PC Liberia 46318/35 2007 MAN B&W 9K80MC- 32446 C/E 07.12.201318.04.2014 EOC

HS Smetana Hansa Shipping Stargate Worlwide PC Liberia 23376/17 2006 MAN B&W 7S60MC- 15826 C/E 24.05.201303.10.2013 EOC

HS Humboldt Hansa Shipping Stargate Worlwide PC Malta 67679/49 2004 MAN B&W 9K90MC- 55942 C/E 13.04.201222.08.2012 EOC

HS Bizet Hansa Shipping Stargate Worlwide PC Liberia 46318/35 2007 MAN B&W 9K80MC- 32446 C/E 10.09.2011 09.01.2012 EOC

HS Smetana Hansa Shipping Stargate Worlwide PC Liberia 23376/17 2006 MAN B&W 7S60MC- 15826 C/E 02.03.2011 03.07.2011 EOC

* or industry sector if ashore

** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off
*** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract
6/9
Summary of Experiences (in number of years)
Years as/ Bulk
Container Tanker Roro Cruise Supply
on carrier
Master -
6.18 0.25
C/E
C/O - 2/E 1.2 0.62 1.5 0.14 0.22

2/O - 3/E 2.64

3/O - 4/E

E/O

Total 10.02 0.62 1.5 0.14 0.25 0.22

Years as/ Sulzer Sulzer SEMT Steam

B&W MAN others
on RTA RND Pielstick Turbine
C/E 6.18

2/E 3.32

3/E 0.68 0.65

4/E

E/O

Total 0.68 9.5 0.65

References
Do you have any objection if we will contact your last employers for
Yes/No No
reference?
If YES please specify why:
If NO please specify below:

employer
Name of company Hansa Shipping GmbH

Name of person to
contact
Address An der Alster 9, 20099, Hamburg, Germany

Tel number 49 4030959319

Please list two contactable referees or past employers

Name of company NSC Shipping GmbH
Name of person to
contact
Address Van der Smissen Str.9, 22767,Hamburg,Germany

Tel number 494036137-213

Name of company
Name of person to
contact
Address

7/9
Tel number

8/9
Bank details
Bank
ING Bank Sort code:
name:
Branch Swift name
Romania INGROBU
name IBAN number:
Sos.
Address: Kiseleff
Account no.11-13
Strelciuc
Account
name/ Dan RO40INGB0000999900083029
number:
Title Sergiu

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; further, 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.

Date__27.06.2017_ Signature_______________________

* The company may contact my previous employer for references.

9/9