APPLICATION FORM PHOTO

(FOR DECK OFFICERS)

GENERAL INFORMATION
Position -       Available from -       Min salary -      
Family name -       First name -       Father’s name -      
Date and Country of birth -       Nationality -      
Home address -      
Phones -       Mob. -       E-Mail -      
English language knowledge Excellent Good Satisfactory Poor
Marital status -       Children (name/D.O.B.) -      
Next of kin (full name/relation) -      
Education -       US Visa

RECORDS OF SEA SERVICE

Cellular /
Ship’s name TEU/ Country Owner/ Period
Type DWT Gear / nbr*tons Position
(year built) RFR_TEU (Flag) Manager from (d/m/y)
capacity till (d/m/y)
     
                                               
     
     
                                               
     
     
                                               
     
     
                                               
     
     
                                               
     
     
                                               
     
     
                                               
     

CONTACT DETAILS OF PREVIOUS EMPLOYERS

Name of ship Crewing Agency / Shipowner Telephone numbers / Address Person in charge

                       

                       

                       

                       

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 NATIONAL PASSPORTS DETAILS
National Passport #       Issued       Exp      
Issued by      
International Passport (OVIR) #       Issued       Exp      
Seaman’s Passport #       Issued       Exp      

NATIONAL DOCUMENTS AND CERTIFICATES

Competency Grade       #       Issued       Exp      
Endorsement of Competency #       Issued       Exp      
STCW`78/95 – A-VI/1 (Basic Safety) #       Issued       Exp      
(personal survival, fire prevention, elementary first aid & social responsibilities)
Proficiency in survival craft #       Issued       Exp      
Advanced fire fighting #       Issued       Exp      
Medical first aid #       Issued       Exp      
Ship’s medical care #       Issued       Exp      
Radar Observation & Plotting #       Issued       Exp      
Automatic Radar Plotting Aids #       Issued       Exp      
GMDSS Operator #       Issued       Exp      
Endorsement of GMDSS #       Issued       Exp      
Hazardous Cargo #       Issued       Exp      
Ship’s Security Officer #       Issued       Exp      
Bridge Team Management #       Issued       Exp      
Bridge Resources Management #       Issued       Exp      
Large Vessels Handling #       Issued       Exp      
Crowd Management #       Issued       Exp      
ISM Familiarization #       Issued       Exp      
US Visa Issued       Exp      
OTHER DOCUMENTS AND CERTIFICATES
      #       Issued       Exp      
      #       Issued       Exp      
      #       Issued       Exp      
      #       Issued       Exp      
FLAG STATE DOCUMENTS
Document Country Number Issued Expired
            #                  
            #                  
            #                  
            #                  

NOTES (for office use only)

РАЗРЕШЕНИЕ
на сбор и обработку персональных данных

Заполняя и отсылая эту анкету, в соответствии с Законом Украины «О защите баз персональных данных» от
01 июня 2010 года № 2297-УІ, даю согласие ООО «ВИТА МАРИТАЙМ» на сбор и обработку моих
персональных данных, в том числе данных, касающихся здоровья, в картотеках и/или электроном виде, с
целью трудоустройства на работу за границей (на суда иностранных судовладельцев), для обеспечения
реализации хозяйственно-правовых и гражданско-правовых отношений, трудовых отношений, отношений в
сфере управления человеческими ресурсами и ведения делопроизводства, подготовки в соответствии с
законодательством статистической и другой информации.

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 INTERVIEWED
     

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