APPLICATION FORM

Position applied for: Deck cadet

Date of availability: 25/03/2022 Last salary: 0$

GENERAL INFORMATION

Surname Khalvashi Date of birth 30/08/2000

First name Ilia Place of birth Georgia
Nationality Georgian Home telephone 0422243869
Mobile Phone +995551179006 Email address Ilia.khalvashi228@gmai.com

Home Address Inasaridze 14 appart 41

Documents/Certificates Held Document No. Place Issued Date Issued Expiry Date

Passport international 61001084057 Georgia 07/09/2020 07/09/2030

US Visa - - - -
Seaman's Identification Card 20-01-013619 Georgia 08/12/2020 08/12/2025
National License – Class:
Endorsement

LAST 5 YEARS SEA SERVICE DATA

VESSEL'S NAME & ENGINE / DWT/ kW RANK PERIOD COMPANY FLAG

IMO Number VESSEL
TYPE
SKL 8NVD 48 -
,,Cadet’’763420 Deck GEORGI
2u/training 947/656.22
cadet
10/03/2021- BSMA
2 vessel A
10/09/2021

I hereby explicitly consent that my personal data can be captured, processed and stored by the crewing agents and prospective
employer as is necessary for the company to offer me employment on board one of their vessels under crewing management. This
includes, but is not limited to, sharing my data with owners, charterers, port agents, manning agents, travel agents, marine authorities
or other organizations. The prospective employer undertakes to use this information solely in connection with assessing whether to
offer me employment, and for no other purpose. In accordance with GDPR, I understand I have rights regarding my data, and can
contact the crewing agent at any time to exercise these rights.

I hereby affirm that all the information provided by me in this Form is true and correct to the best of my knowledge.
Date: 4/19/2022
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