Marlow Navigation Co. Ltd.

25-A, Carl Marx Street,

3rd Floor, Office No 303
183025 Murmansk Russia
Web: http://www.marlow.com.cy/

Crew Department Tel: +7-8152-440420 - Email: trust@m51.ru

SEAFARER'S APPLICATION FORM - Page 1 of 3 - PERSONAL DATA

PERSONAL INFORMATION - RANK: 3rd Engineer

Family Name Amosov First Name (s) Mikhail
Birth Date 31.03.1990 Birth Place Murmansk
Nationality Russian Federation Religion
Marital Status Single No. of Children None
Height (cm) 186 Weight (kg) 80
Nearest Airport Murmansk Color - eyes/hair Eyes: Brown Hair: Brown
ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any)
Street & Nr. Kapitana Maklakova str. 29 Email Address Abrikosov.90@mail.ru
Location Russia Mobile Phone +79095612121
City Murmansk Residence Phone
State, Country Murmansk region Fax
Postal (ZIP) Size: cap/overals/boots C: 59 O: 52 B: 43
Code
NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary)
Family Name Amosova First Name(s) Vera
Nationality Russian Federation Relationship Single
Street & Nr. Mira str. 23 Email Address
Location Russia Mobile Phone +79095612122
City Murmansk Residence Phone
State, Country Murmansk region Fax
Postal (ZIP) P.O. Box (if any)
Code
REMARKS
Requested Rank 3rd Eng Availability Date ASAP
Prefer. Vessel Any Minimum Salary 2000$
Type
English Language Skills Spoken: fluent / good / average / poor - Written: / good / average / poor
Other Foreign Languages None
Professional School / Murmansk Maritime College 2007-2012
Academy - Name & Period
(From - To)
Foreign Crew Experience Norwegian
(specify nationalities)
Other Skills Welding
Further Remarks

Please advise how you heard Newspaper / Advert / Google / Internet / Relative / Other Seafarer
about Marlow Navigation: School / University / Other sources ……………………..
(underline appropriate
option)
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge.
Date: Signature:
Note: This form can be returned per email without signature - please ensure however to send a signed printout for our records afterwards
per mail (e.g. with the passport photos and photo copies required). Please sign all 3 pages of the application form separately.

Attn.: Marlow Navigation - Crew Dept. (AG)

SEAFARER'S APPLICATION FORM - Page 2 of 3 - LIST OF DOCUMENTS

Please note that due to legal requirements boarding is only possible after we are in possession of photo copies of all listed
documents and certificates - in urgent cases you may therefore have to send them email (color scans in .jpg format –
max. 600 pixel wide and max. 900 pixel high) or by fax or courier. Passport photos may arrive later (by mail).

Family Amosov First Mikhail Rank 3rd Engineer

Name Name(s)
A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES
Document Name (Desciption) Document Number Country Issue Place Issue Date Exp. Date
Passport (загранпаспорт) 72 5019116 Russia Murmansk 18.06.13 18.06.23
Seaman's Book (паспорт моряка) 0401847 Russia Murmansk 16.08.18 15.08.23
Seaman's Book (flag state)
Seaman's Book (flag state)
Visa - United States (type C1/D)
Visa - Others (Work/Resid. Permits)
Medical Examination Report 33265034 10.02.19 10.02.20
Drug & Alcohol Test
Vaccination against Yellow Fever
Vaccination against Cholera
Passport Photos please mail 6 for deck officers & 4 for other ranks (required for flag states)
B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES
- deck & engine certificates & endor- - radio certificates & endorsements - nav., deck, technical & management
sements (officers / ratings) - safety training (surv., fire, medical) courses (radar/ARPA, ISM, Marpol,
- electrical & reefer certificates - tanker courses (oil, chem., gas) simulators, computer, welding etc.)
- cook & steward certificates - passenger vsl, roro, hazmat courses - any flag state certificates
Document Name (Desciption) Document Number Country Issue Place Issue Date Exp. Date
Certificate of competency - MMK201141054 Russia Murmanks 27.06.17 03.05.22
GMDSS
GENERAL/OPERATIONAL
ENDORSEMENT GMDSS
RADAR/ARPA
ADVANCED FIRE FITING 0733447 Russia Murmansk 05.05.17 05.05.22
PROFICENCY IN SURVAVAL 0733916 Russia Murmansk 04.05.17 04.05.22
CRAFT AND RESCUE BOAT
PERSONAL SURVIVAL
MEDICAL FIST/MEDICAL CARE 0734049 Russia Murmansk 12.05.17 12.05.22
SSO

CAYMAN ISLANDS
ENDORSEMENT
ISM TRAINING

INTERNAL SMS AUDITOR

Basic safety Training 0806048 Russia Murmansk 03.05.17 03.05.22

Security-related training 0734441 Russia Murmansk 17.05.17 17.05.22

Date: Signature:
 Attn.: Marlow Navigation - Crew Department (Administration Group)

SEAFARER'S APPLICATION FORM - Page 3 of 3 - SEA SERVICE (LAST 10 YEARS)

Please indicate your sea service in the last 10 years as exactly as possible - required are the actual sign-on and sign-off dates according to
the service certificates resp. seaman's book entries. To speed up processing kindly indicate phone and/or fax numbers of your previous
employers. Ship sizes are to be indicated in gross tons, total engine output in kilo Watt (1 kW = 1.34 bhp) to go along with STCW
limitations. Please attach evidence for the listed sea service (copies of seaman's book entries, service certificates etc.). The information
provided may be passed on to our clients and to flag state administrations to allow for verification of rank experience. Please use the
European date format (DD.MM.YY).

Family Name: First Name(s): Date of Birth:

Vessel's Name Flag GT kW Ship Eng.Make Rank S/On S/Off Employer (company
Type Date Date to contact for
reference)
Vasiliy Glovnin Russian 2460 Fishing Wartsila 4th Engineer 17.01.13 30.03.13
Fed. Vessel

Pavel Vavilov Russian 8238 Bulker Man DMR 4th Engineer 17.09.13 30.01.14
Fed.

Zapolyarye Russian 9480 Bulker Man B&W 4th Engineer 21.07.14 20.11.14
Fed.

Akademik Russian 3840 Seismic MaK 3rd Engineer 09.06.15 17.09.15

Nemchinov Fed. Researc
hVessel

Akademik Russian 3110 Seismic Sulzer 3rd Engineer 21.12.15 01.03.16

Shatskiy Fed. Researc
hVessel

Akademik Russian 3840 Seismic MaK 3rd Engineer 28.06.16 24.10.16

Fed. Researc
Nemchinov hVessel

Oksino Russian 852 Fishing SKL 4th Engineer 02.02.17 24.04.17

Fed. Vessel

Morskoy Briz Russian 852 Fishing SKL 4th Engineer 12.03.18

Fed. Vessel

Date: Signature:

С автоматизированной обработкой моих персональных данных указанных в анкете, их передачей и хранением в целях
трудоустройства согласен.
Подпись:_______________________
Дата:______24.08.19_____________________
Готовность в рейс с:____25.08.29__________
Согласие на обработку персональных данных
В соответствии с требованиями федерального закона от 27 июля 2006 года №152-ФЗ( о персональных данных)
Я_Амосов Михаил Павлович, паспорт__РФ________, серия____4710__________, номер___278971____, выдан___Отделом
УФМС России по Мурманской области в Октябрьском АО города Мурманска_____________ Дата выдачи
___14.12.2010______________________
(дата, кем выдан)
зарегистрированный по адресу____Улица Мира д23 кв 54__________________________
____________________________________________________________________________
Выражаю свое согласие на размещение моих персональных данных, указанных в «Application Form», в базе данных OOО
«Траст шиппинг в целях трудоустройства, а так же на осуществление со всеми данными, указанными в «Application Form»
следующих действий: сбор, систематизация, накопление, хранение, уточнение, обновление, обработка(в том числе
автоматизированная), использование, распространение(в том числе трансграничная передача и передача третьим лицам) в
целях трудоустройства.
Подтверждаю, что все сообщенные мною персональные данные достоверны.
Согласие дано на неограниченный срок.
Отзыв настоящего согласия производится в письменной форме.

Подпись___________________________________________________
ФИО оператора _____________________________________________
Адрес оператора: г. Мурманск, ул.Карла Маркса 25-А, офис № 303