insert

PHOTO
here

Readiness
Last salary
LSM Application Form Deck Officers
1. Personal Data

Surname Name Father's Name Permanent address:

Citizenship Date of birth Place of birth Phone:

Mobile:
SKYPE
E-mail:
Document No. Date of issue Place of issue Valid until
Passport (Travelling)
Seaman’s Book
Liberian S. B.
Panamanian S. B.
Ukrainian Civil Passp.
Other

2. Visas
Country Visa Type/Class No. Date Issued Place Issued Valid Until

USA
Australia
Crew Department Appendix 1 Revision 02 Page 1 of 7
SCHENGEN

3. Marine Education
Full Name of School Qualification From Till

4. Sea experience (Last 5 years)

In chronological order - Last vessel on top

№ Rank Vessel Flag Year of Type of D.W.T Cranes/Type Grab Owner or Management From / To Reason of
build vessel SWL yes/no Co /Country departure
1
2
3
4
5
6
7
8
9
1

Crew Department Appendix 1 Revision 02 Page 2 of 7

 5. Highest Competency certificate held:

Issuing authority Grade/ STCW’95 Capacity Certificate No. Date of issued Valid until

National Certificate of Comp

STCW 78/95 Endorsement
Netherlands
Panamanian
Liberian
MPA Singapore

6. Certificates/Courses

Certificates of STCW 78/95 Number Date of issue Place Expiry date

Basic Safety Training and Instruction (A-VI/1)
Basic Sea Survial/Personal Survial Techniques ( A-VI/1-1)
Fire Prevention & Fire Fighting ( A-VI/1-2

Elementary First Aid (A-VI/1-3)

Personal Safety& Social Responsibility (A-VI/1-4)
Proficiency in Survival Craft, Rescue Boats (A-VI/2-1)
Medical First Aid (A-VI/4-1)
Medical care on board (A-VI/4-2)
Crew Department Appendix 1 Revision 02 Page 3 of 7
 Advanced Fire Fighting (A-VI/3)
ARPA-Management Level ( A-II/2)
ARPA –Operation Level ( A-II/1)
Electronic chart Display and Information System
course (ECDIS) (A-II/1)
Ship safety officer IMOA 741(18)
Ship Security Officer (STCW A – VI/5 and ISPS Code)
GMDSS
Endorsement GMDSS (VI/2)
Ship Security Officer (STCW A – VI/5 and ISPS Code)
Issued under STCW 95
Security Awareness (A-VI/6-1)
Designated Security Duties (A-VI/6-2)
Bridge team management (A-II/2)
Carrying Dangerous & Hazardous cargo (B-V/b, B-V/c)
Bridge Resourses Management (B-VIII/2)
Process Control Instrument

Ro-Ro passenger ships

Crowd management ( A-VI/2)
Familiarization training Ro-Ro ships (A-V/2)
Safety Training ((for personnel providing direct service to
passengars)
Passengers safety cargo safety, hull integrity ( A-V/2)
Crisis management and human behavior ( A-V/2)

Crew Department Appendix 1 Revision 02 Page 4 of 7

 7.Additional information

Excellent Good Satisfactory Poor

English language
Computer proficiency Excellent Good Satisfactory Poor

Nationalities of crew sailed with:

Bank details

Next of Kin
Marital Status

Overall, height, weight, shoes size

Medical Certificates included yellow fever, cholera

Nearest airport

Crew Department Appendix 1 Revision 02 Page 5 of 7

 English - Marlin/Ces 4.1 tests

Please complete addresses of your previous employers for references

Company Tel.: Company Tel.:

Address Address

I certify that above information is true and accurate to the best of my ability and that no Certificate of Competency, Licenses or Visas issued to me has
ever been revoked or suspended.

I have been advised and agree to recover expenditure of Shipowner and/or Crewing Agency, which can be occurred due to wrong information or faulty
documents from me.

I understand that previous employers may be asked for information concerning my Employment record with them and I hereby release from all liability
or damage those individual or companies who provide such information

Signature____________________ Date ________________

Crew Department Appendix 1 Revision 02 Page 6 of 7

 Я, , в соответствии с Законом Украины «О защите персональных данных» от 01.06.10 №2297-VI, даю свое согласие на включение моих персональных данных в БПД
«КЛИЕНТЫ» ООО «П-Стрим, ЛТД» в виде картотеки и/или автоматизированной информационной системы, а также на их обработку (сбор, регистрацию, накопление, бессрочное хранение, изменение, обезличивание,
уничтожение, обновление, адаптацию, использование, распространение, реализацию, передачу в полном объеме или частично распорядителям или третьим лицам) без дополнительного письменного уведомления об
этом в мой адрес, с целью оказания предприятием посреднических услуг по моему трудоустрой ству на судах отечественных или иностранных судовладельцев, независимо от страны их местонахождения.

Я письменно уведомлен о включении моих персональных данных в БПД «КЛИЕНТЫ» ООО «Л-Стрим, ЛТД», о ее местонахождении и целях сбора данных, о лицах, которым будут передаваться мои персональные
данные и о моих правах в связи с этим

Seaman 2012 (signature)

Crew Department Appendix 1 Revision 02 Page 7 of 7