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Application Form
Section 1 Position
Position Applied for
Lowest Position Acceptable
Date of Availability
Section 2 Personal Details
Family name / Surname
First Name / Given Name
Date & Place of Birth Date Place
Nationality
Permanent Address

Present Address

PPE information SAFETY SHOES SIZE

COVERALL SIZE
Present Contact Number
Fax Number
Mobile Number
Email Address
Nearest Airport
Section 3 Passport and VISA details
Country of Issue
Date Issued USA Visa - Type B1/OCS
Place Issued USA VISA Expires
Passport Number USA Visa - Type C1/D
Passport –Expires USA VISA Expires
Secondary passport or Dual Other Country Visa
nationality
Visa Expiry
Section 4 ( hi-light as required ) Seaman book / Discharge book / Seaman Record Book / CDC
Issuing Country & Place
Number Date Issued
Expiry Date (if any)
Section 5 Next of Kin – this is important information we require- Don’t ignore it
Full Name / Relationship
Any dependents / Children (incl. age )
Address
Contact Numbers

Section 6 STCW95
Highest Certificate of
Competency / Licence Held
 Class / Grade/Capacity STCW95 CODE
STCW95 ISSUING CERTIFICAT DATE EXPIRY
CODE COUNTRY E No ISSUED
Navigational watch Rating
Efficient Deck Hand
Engine Watch Rating
Cook Part 1
Cook Part 2
Other ????

Section 7 STCW95 Dangerous Cargo Familiarisation

Petroleum…………….
Liquefied Gas……….
Liquid Chemicals…….
A-V/1 Certificate No Issued Expires
A-V/1
A-V/1
A-V/1
Section 8 STCW95 related Courses Attended and Certificates Obtained

Name of Course / Certificate

STCW Code Place Issue Date Cert No Expiry Date
Personal Survival Techniques
Basic Sea Survival / Training
Fire Prevention & Fire Fighting
Elementary First Aid
Personal Safety & Social Responsibility
Proficiency in Survival Craft & Rescue
Boats
Proficiency in RESCUE CRAFTS
Advanced Fire Fighting
Medical & First Aid
Ship Security Officers Course (SSO)
Issued under STCW95
Medical Certificate / HEALTH
Certificate
Drug and Alcohol test certificate
YELLOW FEVER
ISM Code
Hygiene Training
Crowd Control
Passenger Safety
Designated Security Duties
MARLIN’s English Test
IELTS-English TEST

Section 9 SCORE
OFFSHORE
INDUSTRY
COURSES
Fast Rescue Craft Coxswain
Daughter Craft Coxswain
Boatman Certificate
BOSIET
HUET
FOET
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
Re-Breather training
Initial Standby vessel crews training ( ITSO )

Section 12 References

Name of company
Name Person to be contacted
Address
Tel No
Email Fax

Name of company
Name Person to be contacted
Address
Tel No
Email Fax
 
Section 15 Record of Sea Service (All Dates to be entered as dd/mm/yy)
VESSEL COMPANY Type of Vessel DWT GRT or BHP RANK Sign on DATE Sign off DATE
(please delete as reqd)
dd / mm / yy dd / mm / yy
HERMIS BALTLANTA REEFER 3891 2893 cook 19/10/1998 28/03/1999
VYTURYS BALTLANTA REEFER 3891 2893 cook 29/09/1999 19/03/2000
VAKARAS BALTLANTA REEFER 3891 2893 cook 01/07/2000 19/01/2001
VAKARAS BALTLANTA REEFER 3891 2893 cook 04/05/2001 01/08/2001
VAKARAS BALTLANTA REEFER 3891 2893 cook 03/03/2002 01/06/2002
RADVILA ATLANTIC REEFER 3642 2120 cook 01/07/2002 10/11/2002
DANIA KIRSTEN DANIA MARINE DRY CARGO 1882 1570 cook/os 24/10/2003 06/05/2004
DANIA KIRSTEN DANIA MARINE DRY CARGO 1882 1570 cook/os 28/06/2004 07/10/2004
APOLLO MARLOW DRY CARGO 4255 2208 cook 13/12/2004 31/05/2005
FALCON
AFRA MARLOW MPP/CONTAINER 7366 4480 cook 03/10/2005 19/03/2006
NORHOLM SANDFRAKT AS BULK CARRIER 3223 1800 cook/os 22/06/2006 02/10/2006
APOLLO MARLOW DRY CARGO 4255 2208 os 10/02/2007 15/04/2007
CONDOR
STORRINGTON STEPHENSON CLARKE GENERAL 7788 4849 cook 11/06/2007 09/08/2007
DOUGLAS CARGO
ACHIEVER ALEXANDRA MNG CONTAINER 5025 4750 cook 28/01/2009 29/05/2009
ALEXANDRA S ALEXANDRA MNG GEN.CARGO 1431 cook 06/08/2009 09/11/2009
ACHIEVER ALEXANDRA MNG MULTI-PURP. 5025 4750 cook 24/11/2009 17/02/2010
ACHIEVER ALEXANDRA MNG MULTI-PURP. 5025 4750 cook 23/05/2010 08/10/2010
SIMON STEVIN JAN DE NUL FP VESSEL 35034 4×4500 steward 25/03/2011 08/04/2011
MULTRATUG 18 MULTRASHIP TUGBOAT 499 3800 cook/ab 18/05/2011 29/06/2011
DUTCH POWER SEACONTRACTORS AHTS 254 2350 cook/ab 02/08/2011 31/08/2011
DUTCH POWER SEACONTRACTORS AHTS 254 2350 cook/ab 27/09/2011 25/10/2011
ZWERVER 3 SEACONTRACTORS TUG 499 3800 cook 01/10/2012 23/10/2012
Solundoy The Solundoy Trading FISH CARRIER 265 726 Cook – Deck 26/01/2013 22/04/2015
Company