APPLICATION FORM

Rank Date of birth

Surname Place of birth
First name Home address
personal details

Patronymic Home phone Mobil

Marital status E-mail
Next of kin/relationship/address/phon
Test Marlins Test Height Clothes size Hair color
Language knowledge (english)
Result Result Weight Shoes size Eye color
Education University (School, College) Year of graduation Speciality

Document Grade Number Place of issue Issued date Expire date

Documents

Seaman's book
Passport (national)
Passport (foreign)
Visa (USA, others)
Seaman’s passport (Cyp., others)
CERTIFICATE OF COMPETENCY of
GMDSS
RADAR, ARPA
BASIC SAFETY TRAINING EVIDENCE
SURVIVAL CRAFT & RESCUE BOAT
Certificates

ADVANCED FIRE FIGHTING

MARPOL/SOLAS
MEDICAL FIRST AIDS
MEDICAL CARE
SSO
PHYSICAL EXAMINATION REPORT
YELLOW FEVER
D & A TEST
HAZMAT/Carriage of dang.&hazard.subst.
Special training

HAZMAT training program "C", title 49 (USA)

Oil tanker training program
Chemical tanker training program
Other courses:

Type of vessel Owner's name Date Date

Name of vessel Flag Rank
DWT Crew management company from to
Previous experience for last 5 years

Nationality of crewmembers sailed with: Your comments:

Remarks:

Recommendations min wage

Phone of last shipowner (Crew company) expected wage
Others: expect.duration
Application form readiness to work
is accepted by Date Signature of applicant