UKRAINA MARITIME AGENCY

1, Preobrazhenskaya Str., office 7, Odessa, 65082, Ukraine. Tel : +38-0482-378578, 321191, 332677 Tel : +38-0487-289400, 136670 Fax :+38-0482-345332 photo

APPLICATION FORM (O)

A1 Position B1 B2 B3 B4 B5 Full Name (Surname, First Name, Middle Name): Date and country of birth: Home address: E-mail: Phones: English language knowledge: excellent good satisfactory poor A2 Second choice

Australian visa:

Exp.

US visa:

Exp.
Period from (d/m/y)
Position

Records of Service for last 7 years

Ships name Year of built Type
Cont - TEUS, PCC - units

DWT GRT

Country (Flag)

Owner/Manager Crew Agent

till (d/m/y)

Contact details of previous Employers

Name of Ship Crewing Agency / Shipowner Tel. numbers / Address Person in charge

Wage (min) _________________________________

C1 C3 D1 D2 E1 E2 E3 E4 E5 E6

Marital status Next of kin Color of hair: Height: Weight:

C2

Children under the age of 18 -

Color of eyes: Boiler suite size:

Safety shoes size:

National Passport # Issued By Identification Code # Tourist Passport # Issd Seamans Passport AB # Issd Other Countries Seamans Book : Country # Issd Education (educational institution name): Period from (d/m/y) till (d/m/y):

exp exp exp

F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 F11

Certificates Competency : Grade # Issd exp Endorsement # Issd exp STCW78/95 A-VI/1 # Issd (personal survival, fire prevention, elementary first aid & social responsibilities) Proficiency in survival craft # Issd exp & Rescue Boats Advanced fire fighting # Issd exp Ships medical care Radar Observation & Plotting Automatic Radar Plotting Aids GMDSS Endorsement Ships security officer Hazmat Others: # # # # # # # Issd Issd Issd Issd Issd Issd Issd exp exp exp exp exp exp

G1 Yellow Fever: Last medical examination:

Medical examination and vaccination issue date issue date

Remarks: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________

Seafarers Signature Date

Trading route of the previous vessels (whether transited through Panama, Suez Canal, Keil Canal)

Major achievements at sea if any (handled crisis situations)

Nationalities of crew served

Type of cargoes carried (for tankers please mention experience on cow/ig etc.)

Details of oil major , USCG & AMSA inspections

Types of pumps (framo / centrifugal / screw etc.) / AMOS / D experience

Accidents on board /medical sign off : - (give brief details)

References from any office / floating staff , if any

Exp. on VLCC / crude / chem. /LPG. if any :- (pls advise number of months on each type of vessels) VLCC CRUDE CHEMICAL PRODUCT CONTAINER PCC REEFER LPG BULK/GEN.CARGO

Availability date: ___________