APPLICATION FORM

NOTES FOR APPLICATION FORM COMPLETION:

- Please ensure that the below application form is completed in word format.
- Once completed, please fill declaration box on last page and return form to us in word format only.

SECTION 1- SEAFARER PERSONAL DETAILS AND POSITION APPLIED FOR

Position applied for:
Expected Day Rate:
Please attach
Date of availability
passport quality
(dd/mm/yyyy):
photo here
Family name:
First name(s):
Photo must
Date of birth
be taken with white
(dd/mm/yyyy):
background
Place of birth:
Nationality:

Full permanent address:

Full present address

(if different):
Airport distance
Nearest airport:
from address (km):
Email address: Contact number: +
Mobile phone
Skype address: +
number:
Blood group: Positive / Negative:
Height: Weight:
PPE Safety shoe size: PPE coverall size:

SECTION 2- SEAFARER PASSPORT, SEAMAN BOOK AND VISA DETAILS

Document details Document number Country of issue Date of issue Date of expiry
Primary Passport:
Second Passport
(if applicable):
Seaman book:
Flag Seaman book
(if any):
USA Visa Type (if held): USA Visa expiry:
Additional Visa (country): Visa expiry:

SECTION 3- NEXT OF KIN

Full name:
Relationship to Seafarer:

Full address:
Contact number: +
Mobile phone
Email address: +
number:

SECTION 4- HIGHEST CERTIFICATE OF COMPETENCY / LICENCE / CRANE OPERATORS

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CERTIFICATES / OTHER EQUIVALENT CERTIFICATES AND FLAG STATE ENDORSEMENTS
(STCW2010 / STCW78 AS AMENDED)
Class / Grade / Certificate Date of Details of any
Issuing country Date of issue
Capacity number expiry limitations

SECTION 5- STCW2010 (STCW78 AS AMENDED)

CERTIFICATION AND RELATED COURSES
Name of Course / Certificate Place of
STCW Code Date of issue Date of expiry
Certificate number issue
Refresher & updating I / II & III / 2
Basic safety training A-VI / 1
Personal survival techniques A-VI / 1-1
Fire prevention & fire fighting A-VI / 1-2
Elementary first aid A-VI / 1-3
Personal safety & social A-VI / 1-4
responsibility
Proficiency in survival craft & A-VI / 2-1
rescue boats
Proficiency in fast rescue A-VI / 2-2
boats
Advanced fire fighting A-VI / 3
Medical & first aid A-VI / 4-1
Medical care A-VI / 4-2
Radar & ARPA simulator A-II / 1-2
training- management level
Electronic chart display and A-II / 1
information system course Model 1.27
(ECDIS)
GMDSS & endorsement A-IV / 2
Ship Security Officers course A-VI / 5
(SSO)
Proficiency in security A-VI / 6-1
awareness (PSA)
Proficiency in designated A-VI / 6-2
security duties (PDSD)
Bridge team management A-II / 2
Bridge resources B-VIII / 2
management (BRM)
ISM code A.1441 (18)
Engine room resources A-III/1, A-III/2,
management (ERM) A-III / 3,
Helm (leadership and A-II / 2, A-III /
management skills) 2
Tankers familiarization A-V / 1 (1, 2)
Basic Tanker operations (Oil A-V / 1-1-1
Tanker & Chemical Tanker)
Advanced Oil Tanker A-V / 1-1-2
operations
Advanced Chemical Tanker A-V / 1-1-3
operations

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Basic Tanker operations A-V / 1-2-1
(LPG Tanker)
Advanced Tanker operations A-V / 1-2-2
(LPG Tanker)
Crowd Management for A–V / 2-1
passenger ship
Crisis Management and A-V / 2-2
Human Behavior on
Passenger Ships
Basic Training for IGF code A-V / 3-1
Advanced Training for IGF A-V / 3-2
code
Basic Training for ships A-V / 4-1
operating in polar waters
Advanced Training for ships A-V / 4-2
operating in polar waters
Food Handling and Hygiene
Medical / health certificate MLC 2006
Drug and alcohol test
Yellow fever

SECTION 6- OTHER CERTIFICATION / COURSES YOU MAY HAVE

Certificate Place of
Name of Course / Certificate Approvals Date of issue Date of expiry
number issue
Quality Management
Environmental Management
Energy Management
BOSIET / FOET
HUET
CA-EBS
Hydrogen Sulphide (H2S)
HLO / HLA
Helicopter Team Member
Rigging and slinging
Fast Recue Craft Coxswain
Boatman Certificate
Crane Maintenance
Offshore medicals (UK, Norway
or Netherlands)
Re-breather training
Generic ECDIS
ECDIS Furuno
JRC ECDIS
SIMRAD MARIS ECDIS 900
KONGSBERG K BRIDGE-
ECDIS
TRASAS NAVISAILOR ECDIS

ADDITIONAL CERTIFICATION / COURSES YOU MAY WISH TO MENTION TO SUPPORT

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 YOUR APPLICATION
STCW
Certificate Place of
Name of Course / Certificate Code / Date of issue Date of expiry
number issue
Approvals

Marlin’s English test score (Percentage %):

PMS maintenance system- are you familiar with its use (Yes / No):
If yes- please specify the PMS types:

SECTION 7- DYNAMIC POSITIONING (DP) CERTIFICATION

Certificate Date of Date of expiry /
Name of Course / Certificate Approvals Place of issue
number issue unlimited
DP maintenance course
High voltage course
DP induction course
DP simulator course
DPO certificate (details of old
certificate- before renewal)
DPO certificate (details of new
certificate- after renewal)
DP log book details
NUMBER OF HOURS / DAYS DONE WITH VARIOUS DYNAMIC POSITIONING SYSTEMS
Approximate number of hours / days (please clarify which)
System details Senior ETO / Junior ETO / Junior
SDPO DPO
Senior Engineer Engineer

APPROXIMATE TOTAL DP HOURS ON VARIOUS VESSELS / OPERATIONS

Sat diving Cable laying
Air diving Survey
ROV Pipe laying
Well stimulation / intervention /
Drill ship / Semi-submersible
activation
AHTS PSV
FPSO Shuttle Tanker
Construction Rock dumping / Mattressing
Coring Trenching
Heavy lift Accommodation / Gangway

SECTION 8- MEDICAL HISTORY

Particulars Yes / No
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1. Have you ever had to sign off/ repatriated from a ship due a medical reason and been hospitalised?
2. Have you undergone any medical operations in the past?
3. Have you had to consult a doctor during the past 12 months for an illness / accident?
4. Do you have any medical condition that may affect your work?
5. Do you feel healthy and fit to perform the duties of your designated position/occupation?
6. Are you allergic to any medications?
If you have answered Yes to any of the above then specify below

7. Are you taking any prescribed or non-prescribed medications at present?

If yes, please list these medications, their dosage and their purpose / reason for taking:
Prescribed Medications
Dosage Purpose / reason for taking
(please name)

Non-prescribed Medications
Dosage Purpose / reason for taking
(please name)

SECTION 9- GENERAL
Particulars Yes / No
1. Have you ever been involved in a maritime accident, i.e. grounding, fire, explosion, collision
2. Have you ever been rejected by Aramco / Shell or any other Charterer?
3. Have you ever been the subject of a court of enquiry or involved in a maritime accident?
4. Have you ever had a professional license suspended or revoked?
5. Have you ever been convicted of any criminal offence?
6. Have you ever been dismissed due to any reason?
If you have answered Yes to any of the above then specify below

SECTION 10- LAST TWO EMPLOYMENT CONTACT DETAILS

Name of company:
Name of contact person:
Company address:
Contact number: + Email address:
Name of company:
Name of contact person:
Company address:
Contact number: + Email address:

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 SECTION 11A- SEA SERVICE RECORD
PLEASE MENTION FULL RECORD OF SEA SERVICE AS PER SEAMAN BOOK STARTING FROM LAST VESSEL FIRST

Type of vessel Type of For office use

DWT or
(type of engines / DP only
Area of GRT BHP / SWL Sign on date Sign off date
Vessel Company operation in System / Rank Number
operation (please of Crane (dd/mm/yyyy) (dd/mm/yyyy)
case of DP Crane make Number of
clarify)
vessels) and model of days running
days

NOTE for Column 6, please mention:

For Engineers = type of engines; For DPOs = DP System; For Crane operators = Crane make and model

NOTE for Column 7, please mention:

For Officers / Engineers = BHP; For Crane operators = SWL

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 SECTION 11B- AHTS / AHT EXPERIENCE IF ANY (ONLY FOR DECK OFFICERS)
NUMBER OF DAYS WITH VARIOUS OPERATIONS
Vessel name Description of operations (please specify number of days)
(please put last vessel first, Anchor
voyage by voyage) Towing Rig move 4-point mooring
handling

Deep water anchor handling experience- state to what depth in metres:

SECTION 12- ADDITIONAL INFORMATION

VESSEL TYPE YOU ARE INTERESTED IN (PLEASE LIST IN ORDER OF PRIORITY)
1
2
3
4
5
LANGUAGES KNOWN- RATE FROM 1 (POOR) TO 5 (FLUENT)
Language Spoken Written Understood
1 ENGLISH
2
3
ANY OTHER INFORMATION YOU WISH TO ADD IN SUPPORT OF YOUR APPLICATION

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DATA PROTECTION NOTIFICATION:

Here at Ryan (hereafter referred to as Crew Managers), we take your privacy seriously and
treat your personal information with the utmost care. The information you provide will be
stored on our secure database and used in cases of:
 Searching assignment and assignment management.
 Where necessary to comply with laws, regulations or contracts applicable to any of the
employing companies or their businesses and in accordance with any limitation period.
 Where necessary to protect your vital interests

Your personal information will never be sold to third parties or for marketing.

If at any point you believe the information we possess on you is incorrect you can request to
see this information and request to have it corrected or deleted. If you have any query or
complaint, please address any correspondence to our Data Protection Officer on email:
data@ryan-shipmanagement.com

SEAFARER DECLARATION STATEMENT:

I hereby declare that the above facts and information I have provided are true and accurate. I
acknowledge and accept that (i) the Owners/Managers of any vessel to which my application
and/or assignment is organised and (ii) the Crew Managers and associated companies may
each process my personal information (including any of my personal information provided at a
later date) for the purposes of searching assignment, managing assignment, compliance with
laws, regulations and contracts applicable to any of the employing companies or their
businesses and in accordance with any limitation periods and where necessary to protect my
vital interests.

I understand that my personal data will be stored in the Crew Managers’ secure database and
otherwise processed for the above purposes, in connection with, and during the period of my
current period of assignment and thereafter for such further period (if any) as is necessary to
fulfil the abovementioned purposes. I also understand that the abovementioned processing
activities may involve the transfer of my personal information from the Crew Managers to any
of the other companies. This may involve the transfer of my personal information to
jurisdictions whose data protection laws do not provide equivalent protection to my home
country subject to the companies taking appropriate measures to ensure that my personal
data is kept secure at all times. To the extent that my personal information includes sensitive
personal information, I consent to the Crew Managers processing such sensitive personal
information as stated above.

Please select appropriate box, print name, and date in acceptance of the above declaration:

Accepted:
☐ Yes
☐ No
Seafarer name (full name):

Date (dd/mm/yyyy):

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