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Application Form

The document is an application form for maritime positions, requiring personal information, travel documents, STCW certificates, and past experience. It includes sections for medical certificates and a declaration confirming the accuracy of the provided information. The form is structured to facilitate the collection of essential details for potential employment in the maritime industry.

Uploaded by

Milan Kamera
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33 views2 pages

Application Form

The document is an application form for maritime positions, requiring personal information, travel documents, STCW certificates, and past experience. It includes sections for medical certificates and a declaration confirming the accuracy of the provided information. The form is structured to facilitate the collection of essential details for potential employment in the maritime industry.

Uploaded by

Milan Kamera
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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APPLICATION FORM Doc.

Record of personal information, travel documents, certificates and past experience │

SURNAME & NAME


RANK APPLIED FOR │
DATE AND PLACE OF BIRTH
NATIONALITY PHOTO
ADDRESS
PHONES / E-MAIL / OTHER│
NEXT OF KIN: NAME / RELATION
PHONES / E-MAIL │
TRAVEL DOCUMENTS │
NUMBER ISSUE DATE EXPIRY DATE
(dd-mm-yy) (dd-mm-yy)
NAT. SEAMAN’S BOOK │
SEAMAN’S BOOK: ________
PASSPORT (1)
PASSPORT (2)
USA VISA
AUS. SEAFARER’S VISA:

STCW CERTIFICATES│
NUMBER ISSUE DATE EXPIRY DATE
(dd-mm-yy) (dd-mm-yy)
Nat. License :
Grade:
Nat. License Endorsement
Grade:
Flag Endorsement (1):
Flage Name:
Flag Endorsement (2):
Flage Name:
Basic Training
Medical First Aid
Prof. in Surv. Craft & Rescue
Boats
Fast Rescue Boat
Advanced Fire Fighting
Medical Care
Dangerous Cargo Handling
Radar & ARPA
GMDSS
Electronic Charts (Generic)
Electronic Charts (Specific)
Ship Security Officer
Designated security duties
Security Awareness
Bridge Resource
Management
Engine Resource Management
Leadership and Team
Working Skills
Marine Environment Protect.
High Voltage

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APPLICATION FORM Doc.:

Ship Handling

Tankers:
Basic Oil & Chem. Tanker
Operation
Advanced Oil Tanker
Operation
Advanced Chem. Tanker
Operation
Basic Liquefied Gas Tankers
Advance Liquefied Gas
Tanker Operation
Passengers & Ro-Ro:
Crowd Management
Safety Train. for Person. Prov.
Dir. Serv. to Pass.
Crisis Management and
Human Behavior
Pass. Safety Cargo Safety
and Hull Integrity
Others:
Familiarization Training

SERVICES
Vessel Flag DWT/Trade Vessel Company Period (from-to)
Eng type/HP type name Rank (dd-mm-yy)

MEDICAL CERTIFICATES
│Medical Certificate: Issued by: Date:
Vaccination card: │Yellow fever: │Cholera:

DECLARATION │
I hereby confirm that the above information is true and correct to the best of my knowledge. I agree that my CV can
be sent to the partner companies and potential employers.

_____________________ _______________________
(Date) (Applicant's signature)

│FOR OFFICE USE:

Received by: Date: Updated by: Date:

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