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Revision no.

Shipcare Services Srl


CONSTANTA ROMANIA
88 MIRCEA CEL BATRAN STR. TEL: +40 341 730280; FAX: +40 341 730281

e-mail: office@shipcare.ro

SEAMANS

APPLICATION
DATE: VESSEL: PLACE:

FORM

Insert the relevant photo here

RANK APPLIED FOR: AVAILABLE FROM: NAME IN FULL: DATE OF BIRTH: ADDRESS : E-MAIL ADDRESS: FATHER: CIVIL STATUS : MARRIED : NEXT OF KIN: RELATIONSHIP: CHILDREN NAME IF ANY : ENGLISH : GOOD PASSPORT No: S. BOOK No: GRADE OF NATIONAL LICENCE : NO: ISSUE:
NAME OF DOCUMENT ENDORSEMENT TANKERS CERTIFICATE OIL TANKERS CHEMICAL TANKERS LPG NO:

PHONE MOTHER: SINGLE: ADDRESS: PHONE : ADEQUATE ISSUE: ISSUE: POOR EXPIRE: EXPIRE: EXPIRES:
ISSUE DATE EXPIRE DATE

DIVORCED:

CERTIFICATES ISSUED BY ROMANIAN NAVAL AUTHORITY:

IMO VALID CERTIFICATES


NAME OF IMO COURSE PERSONAL SAFETY AND SOCIAL RESP. ON BOARD PERSONAL SURVIVAL TECHNIQUES BASIC/ADVANCED FIRE FIGHTING ELEMENTARY FIRST AID/MEDICAL FIRST AID PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOATS PREVENTION OF MARINE POLLUTION ON SHIPS TRANSPORT AND HANDLING OF DANGEROUS CARGOES MARITIME ENGLISH RADAR NAVIGATION, RADAR PLOTTING AND USE OF ARPA GENERAL OPERATOR FOR GMDSS COURSE GENERAL OPERATOR CERTIFICATE BRIDGE/ENGINE TEAM & RESOURCES MANAGEMENT ELECTRONIC CHART DISPLAY AND INFORMATION SYSTEM SHIP SECURITY OFFICER TANKER FAMILIARIZATION SPECIALIZED TRAINING FOR OIL TANKERS SPECIALIZED TRAINING FOR CHEMICAL TANKERS RO-RO PASSENGER SHIPS/PASSENGER SHIPS 1 NO ISSUE DATE EXPIRE DATE

O T H E R NATIONALITY / A D D I T I O N A L

D O C U M E N T S

OTHER DOCUMENTS E N D O R S E M E N T YELLOW FEVER CARD NO: VALID No NATIONALITY NUMBER ISSUE EXPIRE USA VISA NO: 1 MCV VISA NO: 2

ISSUE DATE
No 1 2

S E A M A N S NATIONALITY NUMBER

EXP. DATE

B O O K ISSUE EXPIRE

PREVIOUS SEA SERVICES


(please insert the last five voyages in chronological order, starting with the last one)
NAME OF THE VESSEL YEAR OF BUILD RANK TYPE DWT OWNER/MANAGER ENGINE TYPE/HP FROM TILL

BANK DETAILS NOMINATED: BANKS NAME: ...... . ACCOUNT HOLDER: .. IBAN CODE: ... .. SWIFT CODE: .. . DECLARATION I, the undersigned, hereby certify that I have furnished all above information in good faith with the purpose of employment with your Company and that all the data is true and can be proven against my original documents (Passport, Seamans book, professional certificates of discharge), which I will produce at any time upon request by employing office, Master, Shipping Company and/or authorized authority. Should any discrepancy from above stated arise, I will be fully responsible for the resulting consequences, including, but not limited to, full charges and costs caused by such fact to involved parties for my employment and for immediate repatriation from the ship. SEAMANS SIGNATURE _________________________ INTERVIEWED BY ____________________