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

PERSONAL INFORMATION
Family Name First Name
Birth Date Birth place
Nationality Weight (kg)
Marital Status Height (cm)
No. of Children
Nearest Airport
ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any)
Street & Nr Email Address
Location Mobile Phone
City Residence Phone
State, Country Fax
Postal (ZIP) Code P.O. Box (if any)
NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary)
Family Name First Name
Nationality Relationship
Street & Nr Email Address
Location Mobile Phone
City Residence Phone
State, Country Fax
Postal (ZIP) Code P.O. Box (if any)
REMARKS
Requested Rank Availability Date
Prefer. Vessel Type Minimum Salary
SUMMARY OF QALIFICATION AND EXPERIENCE
Years with operator
Years in rank
Years on chemical-/oil tankers
Years on LPG tankers
Years on tankers (all types)
English Language Skills
Other Foreign Languages
Professional School / Academy - Name & Period
(From - To)
Foreign Crew Experience (specify nationalities)
Other Skills
Further Remarks
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:

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

Family
First Name(s) Rank
Name
A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES
Document
Document Name (Desciption) Country Issue Place Issue Date Exp. Date
Number

B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES

"- deck & engine certificates & - nav., deck, technical &
"- radio certificates & endorsements
endor- sements (officers / management courses (radar/ARPA,
- safety training (surv., fire, medical)
ratings) ISM, Marpol, simulators,
- tanker courses (oil, chem., gas)
- electrical & reefer certificates computer, welding etc.)
- passenger vsl, roro, hazmat courses"
- cook & steward certificates" - any flag state certificates
Document
Document Name (Desciption) Country Issue Place Issue Date Exp. Date
Number

Date: Signature:
 SEAFARER'S APPLICATION FORM - Section 3 of 3 - SEA SERVICE (LAST 10 YEARS)

Please indicate your sea service in the last 10 years as exact 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 be prepared to provide evidence for sea service that cannot be confirmed by reference check.
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
First Name(s) Date of Birth:
Name
Eng. Employer
Vessel's Maker S/On S/Off (company to
Flag GT Kw Ship Type and Rank
Name Date Date contact for
Model reference)

Date: Signature: