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Application Form

Surname*
Name*
Middle name*
Applying for rank*
Experience at the rank*
Permanent address*
Town*
Street address*
Telephone
Mobile no.*
E-mail*
Next of kin*
Relationship*
Town*
Street address*
Telephone*
Date (DD.MM.YYYY) /place of birth*
Marital status*
No. of children*
Height*
Weight*
Do you have tattoos?*
Visible or not visible?
Citizenship*
ID card no*
Place issued*
Date issued (DD.MM.YYYY)*
Expiry date (DD.MM.YYYY)*
IPC (EGN)

Education & Languages

Education: higher/ secondary*
University/school*
Diploma no.*
Date (year)*
Specialty*
Language proficiency (level)
Language proficiency (level)
Language proficiency (level)

Passport & Visas

International passport No.*
Place of issue*
Date of issue (DD.MM.YYYY)*
Expiry date (DD.MM.YYYY)*
Seaman’s passport No.*
Place of issue*
Date of issue (DD.MM.YYYY)*
Expiry date (DD.MM.YYYY)*
Visa/type
Place of issue
Date of issue (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Other passport No.
Place of issue
Date of issue (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)

Medical Examination

Date of last medical examination (month and year)*
Conviction status*

Certificate(s) of competency

Certificate of competency
Endorsement number
LIMITATION (area/engine size/tonnage)
Number
Country of issue
Date of issue (DD.MM.YYYY)
Date of expiry (DD.MM.YYYY)
Certificate of competency
Endorsement number
LIMITATION (area/engine size/tonnage)
Number
Country of issue
Date of issue (DD.MM.YYYY)
Date of expiry (DD.MM.YYYY)
Certificate of competency
Endorsement number
LIMITATION (area/engine size/tonnage)
Number
Country of issue
Date of issue (DD.MM.YYYY)
Date of expiry (DD.MM.YYYY)
 

Other valid certificates/qualifications

Certificate
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Copy encl.
Certificate
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Copy encl.
Certificate
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Copy encl.
Certificate
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Copy encl.
Certificate
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Copy encl.
 

Summary of experience

Total experience
Number of years at rank
Would you consider sailing at a lower rank?

General Maritime Certificates

 
1. Personal Survival Techniques
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
2. Fire Prevention and Fire Fighting
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
3. Elementary First Aid
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
4. Personal safety and social responsibility
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
5. Proficiency in survival craft and rescue boats
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
6. Competency in Adv. Training in Fire Fighting
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
7. Proficiency in Medical First Aid
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
8. Proficiency in Mediacl Care
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
GMDSS Certificate
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
GMDSS Endorsement
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)

Special Maritime Certificates

 
1. Oil Tanker Familiarization
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
2. Chemical Tanker Familiarization
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
3. Advanced Training on Chemical Tanker Operations
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
4. Ro-Ro Passenger Ship Familiarization
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
5. Crowd Management and Human Behaviour in Crises
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
6. Safety of Passengers, Cargo and Heel Watertightness
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
7. Safety of Passengers (for service staff-attendants on Ro-Ro passenger ships)
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
8. Passenger Ships Familiarization
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
9. Crowd Management and Human Behaviour in Emergency
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
10. Safety of Passengers (for service staff-attend. on pass. ships)
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
11. Specialized training for personnel on passenger ships (including Ro-Ro Passenger ships)
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
12. Proficiency in Security Awareness
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
13. Proficiency for Seafarers with designated security duties
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
14. Marine Environmental Awareness
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
 
15. Proficiency in Ship Security Officer
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)
Other
Number
Date issued (DD.MM.YYYY)
Expiry date (DD.MM.YYYY)

Experience at sea

Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
Type of vessel
Most recent period of service
Total period of service
Highest rank on this type of vessel
Years at rank
 

References

Company name
Position
Period of employment
Company name
Position
Period of employment
Company name
Position
Period of employment
 

Current situation

PLEASE NOTE - THE BELOW GIVEN TABLE IS FOR OUR INFORMATION ONLY AND WILL NOT BE FORWARDED TO PROSPECTIVE EMPLOYERS. DETAILS WILL GO ON TO OUR DATABASE TOGETHER WITH THE REST OF YOUR DETAILS AND CONFIDENTIALITY WILL BE MAINTAINED AT ALL TIMES.

PLEASE COMPLETE IN FULL IN ORDER TO ASSIST US IN MATCHING YOUR REQUIREMENTS AS CLOSELY AS POSSIBLE WITH THOSE OF OUR CLIENTS.

Employment status
Current / most recent employer
Current / most recent annual salary
Type of employment required: (temp/perm etc.)
Lowest rank considered
Availability date(s)
Maximum tour lengths
Leave required
Minimum salary requirements
Voyage type preferred (Deep Sea/Coastal etc.)
Type of vessel required
Any preference for geographical regions
Any vessels not prepared to sail on
Any regions not prepared to sail in
Period of notice required by employer
Аre there any companies you would not consider working for?

Onshore experience

Company
From
To
Position
Remark
Company
From
To
Position
Remark
Company
From
To
Position
Remark
Company
From
To
Position
Remark
Company
From
To
Position
Remark
Company
From
To
Position
Remark
Company
From
To
Position
Remark
 

Excerpt from the candidate's sea practise for last 10 years

Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
Owners/managers
Name of vessel
Type
Flag
GT
KW
KVA
Rank
Service from
Service to
Remark
 
I certify that the aforegiven information is true and accurate to the best of my knowledge
I certify that no certificate of competency or licence issued to me has ever been revoked or suspended and I understand that previous employers may be asked for references.
I have read and give my informed consent in accordance with Regulation (EU) 2016/679
INFORMED CONSENT FORM
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