Application form (Анкета)

Application form (Анкета)

Attach your photo here

1st

2nd

Surname

First name

Middle name

Permanent address:

E-mail:

Date of birth:

Place of birth:

Citizenship:

Min.salary:

Phone (home) №:

Phone (mob.):

Nearest Airport:

INFORMATION RELATIVES

Marital status (married/Single/Divorced):

Number/ age of children:

Next of kin (name/relation):

Next of kin (address):

PERSONAL DATA

Colors of eyes:

Colors of hair:

Special marks:

Height: sm

Weight: kg

Overall size:

Shoes size:

Knowledge of English (Fluent/Good/Satisfactory/Poor):

Other languages:

№

ISSUED

VALID

PLACE OF ISSUE

INTERNATIONAL PASSPORT

Seaman's book

Civil PASSPORT

STCW Certificates

№

Date of issue

Date of expiry

Place of issue

GMDSS Endorsement

Carriage of dangerous and hazardous substances

ARPA (A-I/12, A-II/1, A-II/2, B-I/12)

Personal safety (A-VI/1) (IMO 1.13, 1.19, 1.20, 1.21)

Advanced fire fighting (A-VI/3)

Prof. in survival craft (A-VI/2 p.1-4)

Medical first aid (A-VI/4-1)

Medical care (A-VI/4-2)

Hazardous cargoes (B-V/4, B-V/5)

Safety officer (ISM code)

Crowd management (A-V/3)

Bridge Team Management

Training for person. serving onpassenger ships other than RO-RO pas.ships

RoRo passenger (A-V/2-1,-2,-3,-4,-5)

Ship security (A-VI/6-2)

Ship handling arrangements

Dangerous cargoes certificates

Oil tank. familiarization (A-V/1)

Oil tank.Specialized training (A-V/1,p.9-14)

Chem. tank. familiarization (V/1)

Chem. tank. advanced (A-V/1,p.16-21)

LPG familiarization (V/1)

LPG advanced (A-V/1,p.23-34)

Medical information

ISSUED

VALID

Yellow fever:

Last medical examination:

Drug & alcohol test:

Details of previous sea service

Rank

Name of ship owner

Flag

Name of VSL

Type of VSL

Type of engine

DWT

BHP

From

To

Date: Signature ________________

Дата добавления: 2015-11-04