EMPLOYMENT APPLICATION FORM

Position applied
for
Date of
availability
Surname
Date / place of
birth
Nationality

Second choice

Name / s

/ minimum employment age 18 years

Marital
status

Sex

CONTACT INFORMATION
Home address
Phone
E-mail
Nearest airport

NEXT OF KIN DETAILS

Relationship
Name
NOK address
NOK contact

PERSONEL DETAILS & UNIFORM

Hair color
Eye color
Height (centimeters)

Weight (kilograms)

Working clothes size

Shoes size

EDUCATION
Name of school or academy

Department

From

To

PASSPORTS, SEAMANS BOOKS , VISAS

Name of document
National Passport
National Seamans Book
Seamans Passport (if
applicable)
US C1/D visa

Number

Place of issue

Date of
issue

Date of expiry

MEDICAL AND VACCINATIONS

Name of document
Seafarers Medical
Yellow Fever vaccination
Issue 1 Revision 0
Date: Dec 2012
Crewing Form 2.1

Number

Place of issue

Date of issue

Date of expiry

GOOD WINDS MARINE SERVICES SRL

Bd Mamaia, no 158, 2nd Floor, Room 2, Constanta,
900575
Tel/Fax: +40 241 582 955 , e-mail:
office@goodwinds.ro

Page 1 of 2

EMPLOYMENT APPLICATION FORM

CERTIFICATES (STCW A II/1-4 & A III/1-4)
Name of document
Certificate of
competency
Endorsement
GMDSS

Capacity

Number

Place of issue

Issued

Expire

BASIC TRAINING (STCW A VI/1 & A VI/2-4) AND OTHER CERTIFICATES

Name of document

Number

Basic First Aid

Basic Fire Fighting
Advanced Fire Fighting
Personal Survival Techniques
Personal Safety and Social
Responsibility
Medical First Aid
Medical Care Person in Charge
Proficiency in Survival Craft
Fast Rescue Boat
A.R.P.A.
Radar Observer Certificate
ECDIS Certificate
BRM IMO Model Course 1.22
Ships Security Officer (ISPS-A 13.2)
SSO Endorsement
HAZMAT (Acc US CFR)

Maritime English

MARPOL

SEA SERVICE DURING THE LAST FIVE YEARS

Rank

Company

Issue 1 Revision 0
Date: Dec 2012
Crewing Form 2.1

Name of
vessel

Place of
issue

Date of
expiry

Year
Built

Flag

Type

GRT

GOOD WINDS MARINE SERVICES SRL

Bd Mamaia, no 158, 2nd Floor, Room 2, Constanta,
900575
Tel/Fax: +40 241 582 955 , e-mail:
office@goodwinds.ro

Page 2 of 2

Date of
issue

Engine
type
KW

From

To

EMPLOYMENT APPLICATION FORM

REFERENCES
Company

Contact

Name of
vessel

Tel

Fax

OTHER QUALIFICATIONS AND SHORE BASED EMPLOYMENT

ENGLISH LANGUAGE
KNOWLEDGE
Marlins Test in %
If other test state details

Issue 1 Revision 0
Date: Dec 2012
Crewing Form 2.1

Email

COMPUTER

GOOD WINDS MARINE SERVICES SRL

Bd Mamaia, no 158, 2nd Floor, Room 2, Constanta,
900575
Tel/Fax: +40 241 582 955 , e-mail:
office@goodwinds.ro

Page 3 of 2