Rom Trust S.R.L. Form F-01-1 - APPLICATION FOR EMPLOYMENT (rev.4 / 25.05.

2018)

Family Name: Given Name:

Date and Place of birth:
Height (m): Weight(kg): Overall size: Shoes size:
Wear glasses? Yes/No Dioptric left eye: Dioptric right eye:
Father’s Name: Mother’s Name: photo
Education: Between years: Rank/Rating:
Home address:
Phone no.1: Phone no.2 : E-mail:
Language proficiency (delete as appropriate) English: working good fluent Other working good fluent
language:
MARITAL STATUS: NEXT OF KIN: Family name: Given name:
Date/Place of birth: Relationship: Phone no.:
Children’s Name
Date of birth
PERSONAL DOCUMENTS No. Place issued Date issued Valid / Endorsed until
National I.D. Card
Seaman’s Book
Passport
USA Visa
Australian MCV
Certificate of competency:
Rank & Number
Endorsement
I.M.O. STCW 78/95 CERTIFICATES
Certificate Nr. Date issued Certificate Nr. Date issued
Personal survival techniques Proficiency in fast rescue boats
Basic fire-fighting Tanker familiarization
Medical first aid Specialization in oil tanker
P.S.S.R. Specialization in chemical tanker
Prevention of pollution MARPOL 73/ 78 Specialization in gas tanker
Transport & handling dangerous, hazardous cargoes Bridge/Engine Team & Resource
Management
Maritime English Ship’s Handling & Manoeuvring
Proficiency in survival craft& rescue boats ECDIS
Advanced fire-fighting Bridge Simulator/Engine Room Simulator
G.M.D.S.S. – G.O.C. ISM / ISO Course
Radar navigation, radar plotting, use of A.R.P.A. Ro-Ro / Pass /Ferry
Medical care
Ship Security Officer/Security Awareness Vaccination against yellow fever expire:
P R E V I O U S S E R V I C E - EX P E R I E N C E A T S E A
Built Vessel’s Name Flag Type DWT/ ME/ BHP Rank Period Ship’s Managers and Crewing Agents
GRT from – to (include telephone number)

Date: Applicant signature:

Rom Trust S.R.L. Form F-01-1 - APPLICATION FOR EMPLOYMENT (rev.4 / 25.05.2018)
Rom Trust S.R.L. Form F-01-1 - APPLICATION FOR EMPLOYMENT (rev.4 / 25.05.2018)