1.

Position applied for:

2. Personal Data:

Surname: Name: Father’s Name: Permanent address: Nationality:

Date of birth: Place of birth: Marital status: Next Of Kin Phone:

Mobile:
Email:

Document No. Issued Place Date of expire

PASSPORT

US Visa

3. Certificates

Issuing authority Grade Certificate No Date issued Date of expire

NATIONAL SEAMAN’S
BOOK
NATIONAL
CERTIFICATE OF
COMPETENCY
NATIONAL
ENDORSMENT/STCW
95
STCW95
ENDORSMENT
( Foreign Flag State )
SEAMAN’S BOOK
( Foreign Flag State 1 )

4. Previous Sea Experience:

Company Vessel's Flag DWT(teu’s) M.E. power Type of Rank Service Service
Name Type of M.E. Vessel served From Till
5. Special cargo certification

Courses/Certificate Number Date issued Date of expire

OIL TANKER FAMILIARIZATION
SPECIALIZED TRAINING FOR OIL TANKERS
SPECIALIZED TRAINING FOR CHEMICALS TANKERS
SPECIALIZED TRAINING FOR LIQUIFIED GAS TANKERS
INERT GAS SYSTEM OPERATION

6. IMO Certificates

Courses/Certificate Number Date issued Date of expire

GMDSS
GOC
FIRE FIGHTING
ADVANCED FIRE - FIGHTING
PERSONAL SURVIVAL TECHNIQUES
PROFIENCY IN SURVIVAL CRAFTS AND RESCUE
BOATS
PSSR
MARITIME ENGLISH
PREVENTION OF POLLUTION - MARPOLL
TRANSPORT OF DANGEROUS GOODS
RADAR ARPA, BRIDGE TEAMWORK
MEDICAL CARE
FIRST AID
SHIP SECURITY OFFICER
RO-RO / PASSENGER
FAST RESCUE CRAFT
BRIDGE TEAM MANAGEMENT
ENGINE MANAGEMENT

7. Previous Employers.

Employer Name: Employer Name:

Address : Address:

Telephone : Telephone:
Fax: Fax:
E-mail: E-mail: