Académique Documents
Professionnel Documents
Culture Documents
APPLICATION FORM
Passport
Photograph
RANK APPLIED FOR: OR
(please attach)
Surname/Family Name (as in Passport):
First Name: Middle Name (if any):
Date and place of birth:
Permanent Address:
Telephone No.: Mobile Ph.: Fax:
E-mail: Nearest airport:
Citizenship/Nationality: INN/Personal code:
Marital status: Next of kin name:
Next of kin relationship: Next of kin address:
Next of kin Telephone No.: Mobile Ph.: E-mail:
No of children: Names/Dates of birth:
DOCUMENTS:
Documents: Type Grade Number Place of issue Date of issue Expire date
National
British
Seamans
book (ID)
Liberian
Panamanian
Other:
Other:
Passport National (Travel)
Passport National (Civil)
National
Information
Endorsement (National)
Licence
British
Liberian
Panamanian
Other:
SOLAS (basic)
Proficiency in Survival Craft
Fire Fighting
Advanced Fire Fighting
First Aid
Medical Care
Radar Observer
Other certificates
A.R.P.A.
GMDSS
Ship Security Officer
AMOS
Bridge Team Management
ER Resource Management
Ship's Handling
ECDIS (Electronic Charts)
Safety Officer
Security Training
Petroleum
Endorsements
Chemical
Dangerous
LPG/LNG
Cargo
HAZMAT
Crude Oil Washing
Inert Gas
✘
OTHER PRACTICAL EXPERIENCE (tick the appropriate box)
Yes No Types of Main Engines previously worked with:
Have you sailed on UMS vessels before? Sulzer MAN/B&W Pielstick Kobe Diesel Other Other
Have you had any operational problems
on your last two/three vessels ?
Have you had any ITF exposure? Types of Auxiliaries previously worked with:
Are you aware of "No Alcohol Policy" Yanmar B&W Deutz Dhaihatsu Other Other
ECDIS (Electronic Charts) experience ?
HISTORY
Have you previously, or do you now have a Yes No
problem with drinking alcohol in large amounts :
(alcoholic)? If YES, please give details
Have you ever been dismissed from a company or
vessel? If YES, please give details
:
Have you ever been in trouble with the police?
If YES, please give details
:
Have you had serious injuries, ailments,
diseases? If YES please give details
:
Have you ever claimed on insurance?
If YES, please give details
:
Have you sailed on Tankers equipped with Have you sailed on Tankers equipped with
Hydraulic Deepwell Pumps? Inert Gas Generators ?
Have you sailed on vessels built in Japan / Korea? Have you Vapour Recovery Systems experience?
Have you sailed on vessels in Ice Conditions? Remotely operated cargo systems ?
Oil Major Vetting Inspections experience ? Closed loading / sampling experience ?
USCG TVELL / Letter of Compliance inspections? Closed washing systems experience ?
ISM audits for vessel's SMS ? Tank cleaning required for grade changes ?
Cargo contamination or outturn shortages ?
I hereby certify that all the information provided by me in this form is true and correct to the best of my knowledge.