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Readiness
Last salary
Application Form Raitings No.________
1. Personal Data
Surname
Name
Father's Name
Permanent address:
Citizenship
Date of birth
Place of birth
Phone:
Mobile:
E-mail:
Place of issue
Document
Passport (Travelling)
Seaman’s Book
Liberian S. B.
Panamanian S. B.
Ukrainian Civil Passp.
Other
2. Visas
Country
No.
Visa Type/Class
Date of issue
No.
Date Issued
Valid until
Place Issued
USA
Australia
Other
Crew Department
Appendix 1
Revision 02
Page 1 of 6
Valid Until
3. Marine Education
Full Name of School
4. Sea experience (Last 5 years)
Year of
№ Rank
Vessel
Flag
Type of vessel D.W.T
build
Qualification
Owner or Management Co
/Country
1
2
3
4
5
6
7
8
9
10
5. Highest Competency certificate held:
Issuing authority
Grade/ STCW’95 Capacity
Certificate No.
From / To
From
Reason of
Crew
departure
(EOC or Not) Mixed or Not)
Date of issued
National Certificate of Comp
STCW 78/95 Endorsement
Liberian
Panamanian
Other
Crew Department
Appendix 1
Revision 02
Till
Page 2 of 6
Valid until
6. Certificates/Courses
Certificates of STCW 78/95
Certificate of competetency ( A-1/2)
Endorsement (A-11/2)
Basic Safety Training and Instruction (A-VI/1)
Advanced Fire Fighting (A-VI/3)
Proficiency in Survival Craft, Rescue Boats (A-VI/2-1)
Medical First Aid (A-VI/4-1)
Carriage of dangerous goods (B-V/b)
Number
Date of issue
Place
Expiry date
Number
Date of issue
Place
Expiry date
Hazard Analysis and Critical Control Point (HACCP)(САС/RCP 11969)
Welder’s Approval Test Certificate ( Lloyds, DNV)
Certificate of Proficiency Ship-arc-gas Welder
Tanker Certificates
Chemical Tanker specialized training (A-V/1, c.15-21)
Liquefied gas Tanker specialized training (A-V/1, c. 22-34)
Oil Tanker specialized training (A-V/1, c.8-14)
Crew Department
Appendix 1
Revision 02
Page 3 of 6
Crude oil washing (STCW 3/9)
Inert gas system (MARPOL 73/78)
Tanker familiarization course ( a-v/1)
1. Additional information
Excellent
Good
Satisfactory
P oor
LATHE MACHINE SKILLS
YEARS
Good
Satisfactory
P oor
WELDING SKILLS
YEARS
Good
Satisfactory
P oor
English language
Bank details
Next of Kin
Marital Status
Overall, height, weight, shoes size
Medical Certificates included yellow fever, cholera
Nearest airport
English - Marlin/Ces 4.1 tests
Please complete addresses of your previous employers for references
Crew Department
Appendix 1
Revision 02
Page 4 of 6
Tel.:
Company
Address
Signature____________________
Tel.:
Company
Address
Date ________________
Nationalities of crew sailed with:
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____________________
Crew Department
Date ________________
Appendix 1
Revision 02
Page 5 of 6
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 трудоустройству 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
Crew Department
2012
Appendix 1
Revision 02
(signature)
Page 6 of 6
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