“DÖHLE” MANNING AGENCY

ODESSA (UKRAINE) LTD. PHOTO

PERSONAL APPLICATION FORM
Filling does not guarantee employment
Personal data
Rank: Wage Expectation: Date of readiness:

Personal details Seafarer's address Next of kin

Surname: Home № Surname:
Name: Street: Name:
Father's name: Appartment №: Relationship:
Date of birth: City: Home №
City of birth: Country: Street:
Country of birth: Mobile phone 1 №: Appartment №:
Nationality: Mobile phone 2 №: City, Country:
Marital status: Home phone №: Mobile phone №:
Children (under 18): E-mail address: Home phone №:

Maritime education
Number Issue Expiry Place Name of institution Grade From To
Seaman’s Book
Civil Travel Passport
USA Visa
Physical information
Health list — Eyes colour: Height (cm): Shoes size:
Yellow fever — Hair colour: Weight (kg): Boiler suite size:

SEA SERVICE
Period on board Ship’s name Year of DWT Vessel type BHP Type of engine Flag Company Rank
From To build

CES 4.1.─ % Marlins ─ %

Position : NAME:

License and Endorsement

Grade Number Issue Expiry Place Grade Number Issue Expiry Place
Certificate of GMDSS
Competency License
GMDSS
Endorsement
Endorsement

STCW Certificates Another States Seaman's Book and Licenses

Number Issue Expiry Place Number Issue Expiry Place
Basic Safety (A-VI/1) A&B License —

Proficiency in survival
A&B Seaman's book —
craft (A-VI/2)
Advanced fire
Bahamas License —
fighting (A-VI/3)
Medical first aid
Bahamas Seaman's book —
(A-VI/4)
Medical care
Cyprus License —
(A-VI/4)
Hazardous Cargoes
Cyprus Seaman's book —
(B-V/b and B-V/c)
Radar Navigation, Radar
German License —
Plotting & use of ARPA
Ship security officer
German Seaman's book —
(ISPS Code)
Ship safety officer
Liberian License —
(ISM Code)
Bridge team management Liberian Seaman's book —
Marshall Island
Other —
License
Marshall Island
Other —
Seaman's book

Please complete the following datas from previous two companies for references
Crewing company 1 Crewing company 2
Address Address
Person in charge Person in charge
Phones numbers Phones numbers

I understand, that my working contract will be canceled without notification

if any of submitted documents are voted as false. Date: