Name: * Middle Name: Surname:

Birthday: Nationality:

Telephone Numbers: Please include Country and Area Codes

Home

Mobile

Home Address:
Email address:
Nearest Airport

Next of Kin Surname/Name Date of Birth Relation

Address Tel Number Email

Overall size:
Shoes size:

Passport Number: Expiry Date: Place of Issue:

Seaman Book Number: Expiry Date: Place of Issue:

Another Nationality
Expiry Date: Place of Issue:
passport

A) Bachelor Degree
Date: Grade (GPA):

B) Languages
English Poor Fair Good Very good Fluent
Others ( FRENCH ) Poor Fair Good Very good Fluent
Others (ITALIAN ) Poor Fair Good Very good Fluent

CERTIFICATES / COURSES
Highest Competency Certificate Held:

Issuing Authority Grade (1) Certificate No Date Issued Place Issued Valid Until

National
Malta
Panamanian
Cyprus
Other
(1) Specify Whether: Deck Class 2= 1st Mate FG Engine Class 1= 1st Class(M),(S),(M+S)
3= 2nd Mate FG 2= 2nd Class(M),(S),(M+S)

Visas Number Date Issued Valid Until Place Issued

DD/MM/YY DD/MM/YY
 Course / Certificate Certificate Number Date Issued Place Issued Valid Until
Personal Survival Techniques
Elementary First Aid
Medical First Aid
Medical Care
Proficiency in Survival Craft and Rescue Boats
Personal Safety and Social Responsibility
Fire Fighting Basic
Fire Fighting Advanced
Fire Fighting Others ( Specify)
A.R.P.A.
Radar Observer
Radar Simulator
Ship Security Officer
Security Training for Seafarers with Designated
Security Duties - DSD
Security Awareness
General Operator certificate (GMDSS)
Ship Simulator
Bridge Team Management
ECDIS (Course 1.27)
Medical Examination
Yellow Fever Vaccination

Other Courses / Certificates

Dangerous Cargo Certification:

1.Endorsment on NATIONAL Certificate Number Date Issued Place Issued Valid Until

Petroleum
Liquefied Gas
Liquid Chemicals
Crude Oil Washing
Hazmat (CFR 49)

Medical History / Health

Is there anything concerning your medical history or state of health that is
relevant to your application? E.g. recent operations/illnesses…
Yes 0 No

If yes, please explain

Have you ever signed off a vessel due to medical reason? Yes 0No
 Sea-Service Experience
(Recent entry first )

Vessel MAIN ENG

Flag Vessel Type DWT Rank Company From To Period
Name KW