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Position applied for
*

Date available
*
Nationality

General information

Family name
*
Christian name
*
Fathers name
*
Mothers name
*
Date/Place of birth
License nr./Grade
*

Other licenses
US C1/D Visa expire
ID code
Marital status

Children (name/DOB)
Home address
*

Tel
*

Mob
E-mail
Next of kin name/address
English language knowledge
*

Speak other languages
Seaman’s book Exp.
Country Height

Seaman’s passport
*
Exp.
Port

Weight
International p.port
*
Exp.

Country Clothes/shoes
Education
*

I. M. O. Licenses

Endorsement of License

Exp
STCW RULES
A R P A Certificate

Exp
Radar Observation & Plotting Exp
G.M.D.S.S. Certificate Iss

Endorsement exp.
STCW’78/95 – (A-VI/1) — Basic Exp

Advanced Fire Fighting (A-VI/3) Exp
Carrying Dangerous & Hazardous Cargoes (B-V/4,5)

Exp
Bridge Team Management Exp
First aid (medical care) (A-VI/4-1,2) Exp

Proficiency in Survival Craft (A-VI/2) Exp
Dynamic Position Certificate

Exp
Ship’s Safety Officer Exp
Medical Fitness Certificate Exp

Yellow Fever Vaccination Exp
 
Other Licenses
 

Exp.
Exp.

Exp.
Exp.

Exp.

SEA SERVICE (last five years):

Total years of service

Expected min wage, usd *

Place of employment #1:

Vessels name / Vessels type
RANK
FM/TO
GRT

Gear on deck
ENGINE Builder / Model
BHP

Auxiliary Engine Builder / Model
Kind of Automatic
Class of DP

Propul-sion system
Kind of work
FLAG / Year of Built

Reason of discharge
Crew Agency
Principal Company

Place of employment #2:

Vessels name / Vessels type
RANK
FM/TO

GRT
Gear on deck
ENGINE Builder / Model

BHP
Auxiliary Engine Builder / Model
Kind of Automatic

Class of DP
Propul-sion system
Kind of work

FLAG / Year of Built
Reason of discharge
Crew Agency

Principal Company

REFERENCES

VESSEL

SHIPOWNER / SHIPMANAGER NAME / ADDRESS
CONTACT PERSON
TEL No.
FAX No.

E-mail
 
VESSEL
SHIPOWNER / SHIPMANAGER NAME / ADDRESS
CONTACT PERSON
TEL No.

FAX No.
E-mail
 
VESSEL
SHIPOWNER / SHIPMANAGER NAME / ADDRESS
CONTACT PERSON

TEL No.
FAX No.
E-mail
 
DATE OF SIGNING