MEESA APPLICATION FORM

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 Family Name:........................................................
First Name:............................................................
Address:................................................................
Phone: ..................................................................
Fax:........................................................................
E-mail: ..................................................................
Nearest Airport: ...................................................
Date of Birth: ........................................................
Town/Country: .....................................................
Nationality: ...........................................................
Passport No.: .......................................................
Date / Place Issued: .............................................
Expiry Date: .........................................................
US Visa / Type / Expiry Date: ..............................
Seaman’s Book No.: ...........................................
Date / Place issued:..............................................
Expiry Date: .........................................................
Position required:.................................................
Certificate:............................................................
Country of Issue:..................................................
Date of Issue:........................................................
Number:................................................................
Date Revalidated: ................................................
Expiry Date:..........................................................
Limitations:...........................................................
Do You Hold Tanker Certificates:.......................
Numbers / Issue Dates:
DC Endorsement:.................................................
Advance Tanker Training: ..................................
Tanker Familiarization: ……………………..
Date of Last Medical Cert.:..................................
Expiry: ..................................................................
Height:...................................................................
Weight:..................................................................

Next of Kin: .......................................................... Availability Date:..................................................

Relationship: ........................................................
Address if different to above ..............................

12. MARINE COURSES

COURSE NAME NUMBER ISSUE EXPIRY ISSUED BY ISSUED
DATE DATE (AUTHORITY) AT
PERSONAL SURVIVAL
BASIC FIRE FIGHTING
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID
 MEESA APPLICATION FORM

MEDICAL FIRST AID

MEDICAL CARE
PERS. SAFETY & SOC. RESP.
PROF. IN SURVIVAL CRAFT &
RESCUE BOATS
FAST RESCUE CRAFT
G.M.D.S.S.
A.R.P.A. (Management level)
RADAR OBSERVATION
HAZMAT
OIL TANKER
ADVANCED CHEMICAL TANKER
CHEMICAL TANKER
ADVANCE OIL TANKER
GAS TANKER
ADVANCE GAS TANKER
CRUDE OIL WASHING
INERT GAS PLANT
ISM CODE
SHIP SECURITY OFFICER
BRIDGE TEAM MANAGEMENT
DP INDUCTION
DP SIMULATOR
BRIDGE / ENGIINE ROOM
RESOURCE MANAGEMENT.
SHIP HANDLING
INTERNAL AUDITORS COURSE
Prof. of SAT for Seafarers

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 PREVIOUS SEA SERVICE
SHORE EXPERIENCE
EMPLOYER NAME DATE
Period in
& SHIP’S YEAR M.E.
RANK Months & TYPE GRT POWER
CONTACT PHONE NAME BUILT TYPE
FROM TO days
NUMBERS