Application form Crewing

FULL NAME
Last Name: 
First / Middle Name: 

Photo: 

PERSONAL DETAILS
Position Applied For: Accept lower rank: Yes    No
Nationality: Available from:
Mother Language: Civil Status:
Other Languages: Date / Place of Birth:

Permanent Adress: Next Of Kin - Name & Address:
City:
Post Code:
City:
Post Code:
Country:
Country:
Tel:
Tel:
E-mail:
E-mail:
Nearest Airport:
Relationship:

Document
Country
Doc. No.
Issued (dd/mm/yy)
Valid Until (dd/mm/yy)
Issuing Authority & Place
Passport
Seaman's Book
Other
Valid US visa - type C1/D Yes No      
Have you ever been denied for any visa you applied for?  Yes   No
If "Yes", please state the country and reason

EDUCATION
Institution
From(yyyy)
To(yyyy)
Qualification Gained


HIGHEST CERTIFICATES OF COMPETENCY 
Document
Country
Rank
Doc No.
Issued (dd/mm/yy)
Valid Until (dd/mm/yy)
Issuing Authority and Place
Certificate of Competency
STCW 95 National Endorsement

GENERAL OPERATOR CERTIFICATES (Deck Officers Only)
Document
Country
Rank
Doc No.
Issued (dd/mm/yy)
Valid Until (dd/mm/yy)
Issuing Authority & Place
GMDSS – General Operator Certificate

DANGEROUS CARGO ENDORSEMENTS
Document
Country
Level
Doc No.
Issued (dd/mm/yy)
Valid Until (dd/mm/yy)
Issuing Authority & Place
Petroleum

Liquid Chemicals

Liquefied Gas
*Lower=Familiarization; Higher=Specialization

RECORD OF PREVIOUS SEA SERVICE
(Last 5 years) (Most recent experience on top line)
Company 
 Vessel
 DWT
 Type
 Flag
 Year Built
 Main Engine
 BHP
 Rank
Date From dd/mm/
yy
Date To dd/mm/
yy

COURSES ATTENDED
IMO COURSES
Course/Certificate
Reg.Stcw95
Doc No.
Issued (dd/mm/yy)
Valid Until (dd/mm/yy)
Issuing Authority & Place
PERSONAL SURVIVAL TECHNIQUES
BASIC FIRE FIGHTING
ELEMENTARY FIRST AID
PERSONAL SAFETY AND SOCIAL RESPONSIBILITY
PROFICIENCY IN SURVIVAL CRAFT
PROFICIENCY IN FAST RESCUE BOATS
ADVANCED FIRE FIGHTING
MEDICAL FIRST AID
MEDICAL CARE
RADAR ARPA –OPERATIONAL LEVEL
RADAR ARPA –MANAGEMENT LEVEL
TRANSPORT & HANDLING OF DANGEROUS, HAZARDOUS AND HARMFUL CARGOES
PREVENTION OF POLLUTION OF THE MARINE ENVIRONMENT (MARPOL 73/78))
MARITIME ENGLISH,PROBLEMS OF COMMUNICATION IN HUMAN RELATIONSHIPS
SHIP SECURITY OFFICER
BRIDGE TEAM MANAGEMENT
BRIDGE RESOURCE MANAGEMENT
         
IMO COURSES FOR TANKERS
TANKER FAMILIARIZATION
SPECIALIZED TRAINING FOR OIL TANKERS
SPECIALIZED TRAINING FOR CHEMICAL TANKER
SPECIALIZED TRAINING FOR LIQUEFIED GAS TANKER
         
IMO COURSES FOR RO-RO / PASSENGER VESSELS
PROFICIENCY IN CROWD MANAGEMENT ON RO-RO / PASSENGER SHIPS
RO-RO / PASSENGER SHIPS FAMILIARIZATION TRAINING
PROFICIENCY IN PASSENGER SAFETY, CARGO SAFETY, HULL INTE GRITY ON RO-O / PASSENGER SHIPS
PROFICIENCY IN CRISIS MANA GEMENT AND HUMAN BEHAVIOUR ON RO-RO/ PASSENGER SHIPS

MEDICAL HISTORY
Have you ever signed off due to medical reasons?
Yes
No
Have you undergone any operation in the past?
Yes
No
Have you consulted a doctor during the last 12 months for an illness / accident?
Yes
No
Do you have any health or disability problem now?
Yes
No
If the answer is “Yes” to any of the above, please give full details:

          I hereby declare that the information given is true to the best of my knowledge. I also declare that I have not been convicted or refused for entry or declared undesirable by any state. I understand that supplying false information or misrepresentation or omitting any facts or information is cause for my refusal to hire or dismissal. Further, I understand that my employment is conditioned upon a favourable health evaluation. I do hereby authorize an investigation of all statements contained in this Application.

Place: Signature: