APPLICATION FORM

LAST NAME FIRST NAME POSITION

DATE.PLACE
NATIONALITY
OF BIRTH
HOME
E-MAIL
ADDRESS
HOME PHONE MOBILE
SKYPE
NUMBER PHONE
PASSPORT EXPIRY
ISSUE DATE
NUMBER DATE
VISA – VISA – USA VISA -
SCHENGEN EXP EXPIRY OTHER
SEAMAN BOOK
EXPIRY
No. & COUNTRY
MARITIAL
AIRPORT
STATUS
NEXT OF KIN (NAME, NUMBER OF CHILDREN
RELATIONSHIP, ADDRESS) UNDER 18
LANGUAGES /
EDUCATION
LEVEL
SPECIAL SKILLS /
ACHIEVEMENTS
REFERENCES

CERTIFICATES
Number Place issued Date issued Date expires
Cert of Competency
Flag Endorsement
Basic Safety Training
Advance Fire Fighting
Medical First Aid
Medical Care
Designated Security Duties
Ship Security Officer
Pax Ship Training
Proficiency in Survival Crafts
GMDSS
ECDIS Generic
Health Certificate
Other (specify)
Other (specify)
Other (specify)
Other (specify)
Other (specify)

Clipper Palace * 4, Rue de la Turbie * MC 98000 Monaco

Crewing Department: Tel : +377 97 97 84 13 * Fax : +377 97 97 84 11 * veronique.briet@starclippers.com
 APPLICATION FORM

Sea Experience

Ship Name Ship Type Flag GRT Engine Type Company Date From Date To Rank

Clipper Palace * 4, Rue de la Turbie * MC 98000 Monaco

Crewing Department: Tel : +377 97 97 84 13 * Fax : +377 97 97 84 11 * veronique.briet@starclippers.com