APPLICATION FORM

(for deck officers)

Rank Date of birth
Surname Place of birth
First name Home address
Patronymic Home phone Mobil
personal details

Marital status E-mail

Next of kin/relationship/addres
Test Marlins Test CES 4.1 Height Clothes size Hair color
Language knowledge (english)
Result % Result % Weight Shoes size Eye color
Education University (School, College) Year of graduation Speciality

Document Grade Number Place of issue Issued date Expire date

Seaman's ID
Seaman's book
Documents

Passport (national)
Passport (TRAVEL)
Visa (USA, others) С1/D
Schengen visa
Seaman’s passport (Cyp., others)
CERTIFICATE OF COMPETENCY of
GMDSS
RADAR
ARPA
BASIC SAFETY TRAINING EVIDENCE
SURVIVAL CRAFT & RESCUE BOAT
ADVANCED FIRE FIGHTING
Certificates

MARPOL/SOLAS
MEDICAL FIRST AIDS
MEDICAL CARE
DESIGNATED SECURITY DUTIES
BRIDGE TEAM AND RESOURCE MANAGEMENT
SSO
ECDIS
PHYSICAL EXAMINATION REPORT
YELLOW FEVER
D & A TEST
HAZMAT/Carriage of dang.&hazard.subst.
Special training

HAZMAT training program "C", title 49 (USA)

Oil tanker training program
Chemical tanker training program
Other courses:

Type of vessel Owner's name Date Date

Name of vessel Flag Rank
DWT Crew management company from to
Previous experience for last 5 years

Nationality of crewmembers sailed with: Your comments:

Recommendations min wage
Remarks:

Phone of last shipowner (Crew company) expected wage

Others: expect.duration
readiness to work
С автоматической обработкой моих персональных данных, указанных в анкете, их передачей третьим лицам (включая трансграничную) и хранением в
целях трудоустройства в соответствии с Федеральным законом РФ №152-ФЗ согласен. Подтверждаю, что мои персональные данные, указанные в
анкете, являются общедоступными.
Application form is accepted by Date Signature of applicant