HANZA MARINE MANAGEMENT LTD

APPLICATION FORM
Passport
Photo

RANK APPLIED FOR: OR (please attach)

Surname/Family Name (as in Passport):
First Name: Middle Name (if any):
Date and place of birth:
Permanent Address:
Telephone No.: Mobile Ph.: Skype:
E-mail: Nearest airport:
Citizenship/Nationality: Identity No./Personal code:
Marital status: Next of kin name:
Next of kin relationship: Next of kin address:
No of children: Names/Dates of birth:

MARINE EDUCATION HISTORY:

Name of School attended Address (City) Graduated (Date) Speciality

DOCUMENTS:
Documents: Type Grade Number Place of issue Date of issue Expire date
National
British
Seaman's

Liberian
book

Panamanian
Other:
Other:
Passport National
National
Information

Endorsement (National)
Licence

British
Liberian
Panamanian
Other:
SOLAS (basic)
Proficiency in Survival Craft
Fire Fighting
Advanced Fire Fighting
First Aid
Medical Care
Radar Observer
Other certificates

A.R.P.A.
GMDSS
Ship Security Officer
AMOS
Bridge Team Management
ER Resource Management
Ship's Handling
ECDIS (Electronic Charts)
Safety Officer

Petroleum
Endorsements

Chemical
Dangerous

LPG/LNG
Cargo

HAZMAT
Crude Oil Washing
Inert Gas

HMM 001 (May 18 Rev 9)

 MEDICAL INFORMATION
Medical Certificate. Place of issue: Date of issue: Date of Expire:
Height: cm Weight: kg Colour of eyes: Colour of hair:
Yellow fever vaccination expire date (10 years):
UNIFORM INFORMATION:
Height (cm) Chest (cm) Waist (cm) Collar (cm) Shoes size: Sweater size Trousers size

VISAS INFORMATION LANGUAGE INFORMATION

Type Valid Until Good Satisf. Poor Remarks
U.S.A. English
Schengen: Other:
Other: Other:
MULTINATIONAL CREW EXPERIENCE (tick the appropriate box)
British Greek Indian Philipinno Polish Ex USSR

✘
OTHER PRACTICAL EXPERIENCE (tick the appropriate box)
Yes No Types of Main Engines previously worked with:
Have you sailed on UMS vessels before? Sulzer MAN/B&W Pielstick Kobe Diesel Other Other
Have you had any operational problems
on your last two/three vessels ?
Have you had any ITF exposure? Types of Auxiliaries previously worked with:
Are you aware of "No Alcohol Policy" Yanmar B&W Deutz Dhaihatsu Other Other
ECDIS (Electronic Charts) experience ?

HISTORY
Have you previously, or do you now have a Yes No
problem with drinking alcohol in large amounts :
(alcoholic)? If YES, please give details
Have you ever been dismissed from a company or
vessel? If YES, please give details
:
Have you ever been in trouble with the police?
If YES, please give details
:
Have you had serious injuries, ailments,
diseases? If YES please give details
:
Have you ever claimed on insurance?
If YES, please give details
:

REEFER, DRY CARGO CHECK LIST

REEFER CARGOES EXPERIENCE (indicate number of years)
Bananas Citrus Pineapples Kiwi Grapes Apples Mango Melons Vegetables Meat Fish Transhipment

REEFER CHARTERERS / OWNERS EXPERIENCE (indicate number of years)

Dole Chiquita Cool Del Monte Lauritzen Seatrade Green Zodiac Lat.S.C. Lavinia Lomar Blasco

OTHER CARGOES / VESSELS EXPERIENCE (indicate number of years)

Gen.CargoContainers Ro-Ro Bulker Ferry Offshore

OTHER CHARTERERS / OWNERS EXPERIENCE (indicate number of years)

OTHER PRACTICAL EXPERIENCE (tick the appropriate box)

Have you carried any USDA cargo and Yes No ✘
Reefer plant experience: Yes No
completed the checks prior to carriage? Brine ?
Have you sailed without a Reefer Engineer ? Direct Freon evaporation ?
Have you sailed on vessels built in Japan? Reefer containers experience ?
Cargo crane experience? Stevedore damages experience?
Ship's derricks experience?

HMM 001 (May 18 Rev 9)

 TANKER CHECK LIST
CARGO EXPERIENCE (indicate number of years)
Ul
Kerosene Crude
Mogas Gas Oil Condensate Sulpher Naphta Fuel Oil Chemicals Veg. Oil Palm Oil
Jet Kero Oil
Gas Oil

CHARTERERS/OWNERS EXPERIENCE (indicate number of years)

Irving Shevron/ Exxon/ Statoil/ BP/
Shell Elf / Total Conoco
Oil Texaco Mobil Philip Amoco

Number of Years experience on tankers: Number of Years experience in rank:

OTHER PRACTICAL EXPERIENCE (tick the appropriate box)

Yes No Yes No
Have you sailed on Tankers equipped with C.O.W.? Have you sailed without a pumpman ?
Have you sailed on Tankers equipped with Have you sailed on Tankers equipped with
Hydraulic Deepwell Pumps? Inert Gas Generators ?
Have you sailed on vessels built in Japan / Korea? Have you Vapour Recovery Systems experience?
Have you sailed on vessels in Ice Conditions? Remotely operated cargo systems ?
Oil Major Vetting Inspections experience ? Closed loading / sampling experience ?
USCG TVELL / Letter of Compliance inspections? Closed washing systems experience ?
ISM audits for vessel's SMS ? Tank cleaning required for grade changes ?
Cargo contamination or outturn shortages ?

GAS TANKER CHECK LIST

CARGO EXPERIENCE (indicate number of years)
Propane Butane Butadiene Propadiene Propylene VCM Amonia Ethane Methane Ethylene

CHARTERERS/OWNERS EXPERIENCE (indicate number of years)

Shevron/ Exxon/ Statoil/ BP/
Sonatrach Shell Elf / Total
Texaco Mobil Philip Amoco

Number of Years experience on tankers: Number of Years experience in rank:

✘
OTHER PRACTICAL EXPERIENCE (tick the appropriate box)
Yes No Previous Vessels and Types:
Have you sailed on vessels built in Japan / Korea? Full Pressurized Semi Pressurized Atmospheric

Have you experience of cargo contamination

or outturn shortages ?
Oil Major Vetting Inspections experience ? Types of Tanker equipment previously worked with:
USCG TVELL / Letter of Compliance inspections? Reliquifaction:
ISM audits for vessel's SMS ? Booster Pumps:
Pressure control on atmospheric vessels ? Inert Gas:
Inert Gas Generators experience ? Cargo Heater:
Tank cleaning required for grade changes ? Compressor types:
Have you sailed without a Gas Engineer ?
Reliquifaction and cooling Systems experience ?

HMM 001 (May 18 Rev 9)

RECORD OF SEA SERVICE (at least 7 last years, most recent vessel last)
Vessels Year From To
Vessels Name Flag DWT Engine Type BHP Rank Months Company
Type built (date) (date)

PREVIOUS COMPANIES DETAILS FOR REFERENCES

Name of Company Address Name of Manager Telephone Fax E-mail

*Signing this form and/or sending it to Hanza, I hereby certify that all the information provided by me in this form is true and correct to the best of my knowledge.
I allow my personal data to be processed for the recruitment, in accordance with the GDPR (EU 2016/679) and Hanza Marine Management Data Protection Policy.

*Signed by Seaman: Date:

HMM 001 (May 18 Rev 9)