Application Form and

Record of Personal Information and Past

Experience

Doc No:
Valid From:
Version:
Author:

Marine HR TKG - 51
28/06/2005
1
John Williams

Please complete the attached form by hand or electronically (you can type directly in the fields
provided). Please send the completed application to Glasgow.web@teekay.com, or fax it to +44
(141) 243 2100.

Present rank:

Rank applied for:

Date:

Name in full (First, Middle, Last)

Nationality

Photo

Date of birth

Age

Married / Single / Divorced /

Widower

Place of birth

Next of kin

Permanent / Contact address

Name
Relationship
Address

(include international dialing code)

Telephone number

Mobile number

Fax number

Email address

Nearest airport

Colour of hair / eyes

/

Height

Weight

If accepted, date available for service:

U.S. Visa

Type

Valid until

Medical certificate expiry date:

Other Visa

Type

Valid until

Yellow fever vaccination expiry date:

Other Visa

Type

Valid until

Professional Qualifications
Licences

Grade of
licence

Number

Date issued

Place
issued /
Revalidated

Expiry Date

National
(please state)

Bahamian

Liberian

Panamanian

Application Form and

Record of Personal Information and Past
Experience

Doc No:
Valid From:
Version:
Author:

Marine HR TKG - 51
28/06/2005
1
John Williams

Seamans book
number /
Nationality

Place & date

issued

Expiry date

Passport
nationality /
Number

Place & date

issued

Expiry date

Referees:
Name, company
and contact
telephone number

1)

2)

Other professional qualifications / Certificates / Endorsements held

Course / Certificate

Place held

Date held

Date of expiry

Signature:

Application Form and

Record of Personal Information and Past Experience

Doc No:
Valid From:
Version:
Author:

Marine HR TKG - 51
28/06/2005
1
John Williams

Previous Sea Experience

Last

Vessel name

Flag

Deck: Trading area /

Deadweight
Engine: Type & BHP

Type of
vessel

Company
name

Rank

Period
From To

Days / Months

2nd Last

3rd Last

4th Last

5th Last

6th Last

7th Last

8th Last

9th Last

Application Form and

Record of Personal Information and Past Experience

10th Last

Doc No:
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Author:

Marine HR TKG - 51
28/06/2005
1
John Williams
/

th

11 Last

th

12 Last

th

13 Last

th

14 Last

th

15 Last

Other experiences (New buildings / Dry docks / Repair yards / Office secondments, etc.

Application Form and

Record of Personal Information and Past
Experience

Marine Course Attended

Doc No:
Valid From:
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Author:

Marine HR TKG - 51
28/06/2005
1
John Williams

Date Attended

Expiry (if any)

Remarks

Merchant Navy Basic Fire Fighting (3

day)

Merchant Navy Advanced Fire Fighting

(4 day)

Merchant Navy Fire Team Leader /

Command & Control

Basic Sea Survival

Elementary First Aid (1 day)

Medical First Aid (4 day)

Proficiency in Medical Care Onboard

Ship

Certificate of Proficiency in Survival Craft

Specialised Tanker Training (Oil)

Specialised Tanker Training (Chemical)

Specialised Tanker Training (Liquid Gas)

Crude Oil Washing

Inert Gas Plant

Navigation, Radar & ARPA Sim Training

(Operational Level)

Navigation, Radar & ARPA Sim Training

(Management Level)

Electronic Chart Display & Information

Systems

Manned Model Shiphandling

Shiphandling Simulator Course

Engine room simulator Course

Bridge Team Management Course

Engine Team Management Course

Crew Resource Management Course

Crisis Management

Management of Major Emergencies

Personal Safety & Social Responsibilities

Dangerous Goods by Sea (IMDG)

Ship Safety Officer

Ship Security Officer

Efficient Deck Hand

Train the Trainer

Behavioural Safety Awareness

Application Form and

Record of Personal Information and Past
Experience

Doc No:
Valid From:
Version:
Author:

Marine HR TKG - 51
28/06/2005
1
John Williams

Safety Awareness / Accident Prevention

Abrasive Wheel Regulations

Welding

Crowd Management

Crisis Management & Human Behaviour

Passenger Safety, Cargo Safety & Hull

Integrity

Fast Rescue Craft (Boatman)

Fast Rescue Craft (Coxswain)

Draughtercraft Coxswain

Standby Vessel Advanced Medical Aid

Standby Vessel Command & Control

Standby Vessel - Initial Training for

Shipboard operations

Civil Aviation Authority Marine Operators

Certificate

Helicopter Underwater Escape Training

Helideck Assistant

Helicopter Landing Officer

Offshore Emergency Helideck Team

Member

Dynamic Positioning (Basic)

Dynamic Positioning (Advanced)

Any other Relevant Training: