SEA POSITION APPLICATION FORM

This form is to be completed by job applicant by hand or electronically (you can type directly in the fields
provided). Please send the completed application to the email address pertaining to your nationality.

LNGrecruitment.glasgow@teekay.com
LNGrecruitment.manila@teekay.com

Date available for appointment: dd/mm/yyyy

Present rank Rank applied for Date

            dd/mm/yyyy
Name in full (First, Middle, Last) Nationality Photo
           
Date of birth Age Place of birth
dd/mm/yyyy            

Nearest airport Next of kin

      Name:      
Permanent / contact address Relationship:      
     
Address:      

For contact numbers please include international dialing code

Telephone number Mobile number Fax number Email address
                       

If accepted, date available for service: U.S. Visa Type Valid until
dd/mm/yyyy             dd/mm/yyyy
Medical certificate expiry date: Other Visa Type Valid until
dd/mm/yyyy             dd/mm/yyyy
Yellow fever vaccination expiry date: Other Visa Type Valid until
                  dd/mm/yyyy

TEEKAY LNG SEA POSITION APPLICATION FORM ─ DOC NO: FM1400g 1

 Professional Qualifications

Licences Grade of Number Date issued Place issued / Expiry date

licence revalidated
National             dd/mm/yyyy       dd/mm/yyyy
(please state)
     
Bahamian             dd/mm/yyyy       dd/mm/yyyy
Liberian             dd/mm/yyyy       dd/mm/yyyy
Panamanian             dd/mm/yyyy       dd/mm/yyyy
Seaman’s Book             dd/mm/yyyy       dd/mm/yyyy
Passport             dd/mm/yyyy       dd/mm/yyyy
nationality
     

References: Name, company and contact telephone number

1)       2)      

Other Professional Qualifications, Certificates, Endorsements held

Course / Certificate Place held Date held Date of

expiry
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy
            dd/mm/yyyy dd/mm/yyyy

Signature:

TEEKAY LNG SEA POSITION APPLICATION FORM ─ DOC NO: FM1400g 2

Previous Sea Experience
Vessel name Containment Deck Engine Vessel type Steam Full Rank Period Months / Days
type (e.g. Trading area/ Type & BHP (e.g. LNG, or Motor company From – To
No.96, MKIII, Deadweight OIL, LPG - name
(S or M)
IHISPB, Moss) state one only)

Last                                                             /      
     
nd
2 Last                                                             /      
     
rd
3 Last                                                             /      
     
th
4 Last                                                             /      
     
th
5 Last                                                             /      
     
th
6 Last                                                             /      
     
th
7 Last                                                             /      
     
th
8 Last                                                             /      
     
th
9 Last                                                             /      
     
th
10 Last                                                             /      
     
th
11 Last                                                             /      
     

TEEKAY LNG SEA POSITION APPLICATION FORM ─ DOC NO: FM1400g 3

 Vessel name Containment Deck Engine Vessel type Steam Full Rank Period Months / Days
type (e.g. Trading area/ Type & BHP (e.g. LNG, or Motor company From – To
No.96, MKIII, Deadweight OIL, LPG - name
(S or M)
IHISPB, Moss) state one only)

12th Last                                                             /      
     
th
13 Last                                                             /      
     
th
14 Last                                                             /      
     
th
15 Last                                                             /      
     
Other experiences (new buildings / dry docks / repair yards / office secondments, etc.
     

TEEKAY LNG SEA POSITION APPLICATION FORM ─ DOC NO: FM1400g 4

 Marine course attended Date attended Expiry (if any) Remarks
Basic Gas Tanker Training dd/mm/yyyy dd/mm/yyyy      
Advanced Tanker Training (Liquid Gas) dd/mm/yyyy dd/mm/yyyy      
Tanker Fire Fighting dd/mm/yyyy dd/mm/yyyy      
Advanced Fire Fighting dd/mm/yyyy dd/mm/yyyy      
Medical Care dd/mm/yyyy dd/mm/yyyy      
Medical First Aid dd/mm/yyyy dd/mm/yyyy      
Proficiency in Survival Craft dd/mm/yyyy dd/mm/yyyy      
Proficiency in Fast rescue boat dd/mm/yyyy dd/mm/yyyy      
Proficiency in security duties dd/mm/yyyy dd/mm/yyyy      
Ship Security Officer dd/mm/yyyy dd/mm/yyyy      
Bridge Resource Management dd/mm/yyyy dd/mm/yyyy      
Engine Resource Management dd/mm/yyyy dd/mm/yyyy      
High Voltage dd/mm/yyyy dd/mm/yyyy      
Ship handling dd/mm/yyyy dd/mm/yyyy      
LICOS dd/mm/yyyy dd/mm/yyyy      
Kongsberg Step 1 dd/mm/yyyy dd/mm/yyyy      
Kongsberg Step 2 dd/mm/yyyy dd/mm/yyyy      
Furuno FMD 3200 dd/mm/yyyy dd/mm/yyyy      
Furuno FEA 2107 dd/mm/yyyy dd/mm/yyyy      
Kongsberg Bridge ECDIS dd/mm/yyyy dd/mm/yyyy      
SAM Platinum ECDIS dd/mm/yyyy dd/mm/yyyy      
Transas ECDIS - Navigation dd/mm/yyyy dd/mm/yyyy      
Sailor 4000 MFD
DFDE Wartsila W50 / W34 dd/mm/yyyy dd/mm/yyyy      
ABB Propulsion systems dd/mm/yyyy dd/mm/yyyy      
MAN Engine 51/60 dd/mm/yyyy dd/mm/yyyy      
MAN DFDE 51/60 dd/mm/yyyy dd/mm/yyyy      
Wartsila gas reliquification course dd/mm/yyyy dd/mm/yyyy      
MAN ME dd/mm/yyyy dd/mm/yyyy      
MAN MEGI dd/mm/yyyy dd/mm/yyyy      
Burckhardt (compressor) dd/mm/yyyy dd/mm/yyyy      
LNG STS dd/mm/yyyy dd/mm/yyyy      
Azipod Safety Space (H850) dd/mm/yyyy dd/mm/yyyy      
Azipod V technical training (H881) dd/mm/yyyy dd/mm/yyyy      
ABB technical training (H862, H864, dd/mm/yyyy dd/mm/yyyy      
H869, H874)

TEEKAY LNG SEA POSITION APPLICATION FORM ─ DOC NO: FM1400g 5

 Marine course attended Date attended Expiry (if any) Remarks
ABB Azipod training (H883, H886) dd/mm/yyyy dd/mm/yyyy      
Ice navigation basic dd/mm/yyyy dd/mm/yyyy      
Ice navigation advanced dd/mm/yyyy dd/mm/yyyy      
Artic survival training dd/mm/yyyy dd/mm/yyyy      
Honeywell instrumentation & control dd/mm/yyyy dd/mm/yyyy      
Transas sigma ice radar dd/mm/yyyy dd/mm/yyyy      
Basic Gas Tanker Training dd/mm/yyyy dd/mm/yyyy      
Advanced Tanker Training (Liquid Gas) dd/mm/yyyy dd/mm/yyyy      
Tanker Fire Fighting dd/mm/yyyy dd/mm/yyyy      
Advanced Fire Fighting dd/mm/yyyy dd/mm/yyyy      
Medical Care dd/mm/yyyy dd/mm/yyyy      
Medical First Aid dd/mm/yyyy dd/mm/yyyy      
Proficiency in Survival Craft dd/mm/yyyy dd/mm/yyyy      
Proficiency in Fast rescue boat dd/mm/yyyy dd/mm/yyyy      
Proficiency in security duties dd/mm/yyyy dd/mm/yyyy      
Ship Security Officer dd/mm/yyyy dd/mm/yyyy      

Other relevant training

      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      
      dd/mm/yyyy dd/mm/yyyy      

TEEKAY LNG SEA POSITION APPLICATION FORM ─ DOC NO: FM1400g 6