Application form

1.

Last name*:

First name*:
 

(as per Passport)

 Citizenship:
2. Date of birth*: Nationality:
 Place: Country*:
3. Passport No:   
 Issue Date: Expiry Date:
 Place of Issue:
4. Permanent Address: Phone*:
   mob.Phone:
5. Nearest Aiport/Station: E-mail:
6. Present Address: Phone:
7. Civil Status: No. of Children:
8. Next of kin: Relation:
9. Address of next of kin: Phone:

10. Wife and Children's
(up to 18) Name 		Date of Birth Passport No. Date of Issue Date of Expiry Place of Issue

11. Position Applied for: Date of Availability:
 Preferred contract length:Expected Salary:
 Preferred type of vessel:Preferred sailing region:

12. Seaman's Book Number Date of Issue Date of Expiry Country of Issue
Estonian
Russian
Latvian / Lithuanian

13. Certificate of Competency Number Date of Issue Date of Expiry Country of Issue
STCW Endorsement Number Date of Issue Date of Expiry Country of Issue

14. Courses/Certificates Number Date of Issue Date of Expiry Place of Issue
Personal Survival Techniques
Basic Fire Fighting
Elementary First Aid
Personal Safety and Social Responsibilities
Advanced Traning in Fire Fighting
Proficiency in Survival Craft and Rescue Boats
Medical Emergency-First Aid
Medical Care Onboard Ship
GMDSS General Operator Certificate
Radar Observer and Plotting Certificate
ARPA
Oil tanker familiarization / specialized training
Chemical tanker familiarization / specialized
Gas carrier familiarization/specialized training
Dangerous Goods at Sea
Bridge Team and Resource Management
Ship Handling and Maneuvering
ECDIS / Electronic charts
Maritime English
Revalidation course
SSO
ISM Code
Details of any courses/certificates not included in the above to specified in spare or unutilised columns.

15. Schools Attend:
(including Pre-Sea Traning)
Name of School Town / City From To Type of degree/diploma received

16. Languages: Spoken Written Read
English

17. Physical Declaration:
Height: Weight: Color of Hair: Color of Eyes:

Medical Inspection Date Issued:Date of Expiry:Country of Issue
Estonian
Other
VacinationDate of VacinationDate of Expiry:Country of Issue
Yellow Fewer
Cholera
Other

18. Previous Sea Services:
(Datewise upto 10 previous vessels ending with last. Expirience prior to that to be attached separately.)
Name of Vessel Type of Vessel Flag DWT Type of Engine HP Name of Owners or Managers Rank From (day, month, year) To (day, month, year)

# Elec.Officer to mention UMS Experience, if any:
# Radio Officer to mention Radio Equipment make/Satcom/Telex:


20. Boiler Suit size:
T-Shirt size:
Working Shoes size:


21. References (Please indicate at least one person who could give additional information about You)
No Name of referee Company Post Phone no
1.
2.