PERSONAL DETAILS

Position Applied for

Family Name (Surname)
Given Name (First name)
Date of Birth
Nationality
Height
Shoe size

CNP
Father's name
Place of birth
Sex(M/F)
Weight
Size

cm
cm

Photo

kg
S,M,L,XL,XXL

Marital Status

Address
Street
City/Country
Airport(s)
Next of Kin
Relationship
Address
Street
City/Country
Remarks
Dependent(s): (Name and Date of Birth)

Passport No.
Seaman's book No
USA Visa

Tel
Fax
Mobile
e-mail
Tel
Fax
Mobile
e-mail

NATIONAL DOCUMENTS
Issued on
Issued on
Issued on

Issued at
Issued at
Issued at

CERTIFICATE OF COMPETENCY
Issued on
Issued at
Issued on
Issued at

Type
Endorsement

ENGLISH

level = (poor, fair, good,very good,excellent)

FRENCH

level = (poor, fair, good,very good,excellent)

Valid till
Valid till
Valid till

Valid till
Valid till

OTHER FOREIGN LANGUAGES

COMPUTER LITERACY
Yes
If yes, give details of software used:

No

Issued on
Issued at
Valid till
NATIONAL ENDORSEMENTS RELATED TO SPECIAL TRAINING CERTIFICATES for TANKER VESSELS(A-V/1)
Specialized training for gas tankers
Issued on
Issued at
Valid till
Specialized training for chemical tankers
Issued on
Issued at
Valid till
Specialized training for oil tankers
Issued on
Issued at
Valid till
Tanker Familiarization
Issued on
Issued at
Valid till
Issued on
Issued at
Valid till
Issued on
Issued at
Valid till
Romanian National Medical
Yellow Fever
Hepa-B
Epidemic Cert
D+A Pre-Joining test
Chem. Tanker Health
Flag
Medical
Application no.
Temporary license no.

Flag

Seaman's Book No.

MEDICAL and VACCINATIONS

Issued on
Issued on
Issued on
Issued on
Issued on
Issued on

Valid till
Valid till
Valid till
Valid till
Negative
Valid till

FLAG STATE DOCUMENTS( On hand or in-process)

Issued on
Issued at
Issued on
Issued at
Issued on
Issued at
Issued on
Issued at
FLAG STATE DOCUMENTS(On-Hand)
Issued
Competency
Issued
Endorsement
Valid
Type
no.
Valid Type

Positive

Valid till
Valid till
Valid till
Valid till

no.
Valid

GOC no.
Valid

STCW CERTIFICATES 78/95 - RATINGS

Certificates

Number

Place
issued

Date
Issued

Valid
Until

Regulations

Personal Survival
1 Techniques

A - VI/I p.2.1.1; tab A - VI/I -1

Fire Prevention and Fire

2 Fighting

A -VI/I p.2.1.2; tab A - VI/I -2

Emergency First Aid

A - VI/I p.2.1.3; tab A - VI/I -3

Personal Safety and Social

4 Responsibilities

A - VI/I p.2.1.4; tab A - VI/I -4

V - ADDDITIONAL TRAINING
Certificates

Number

Place
issued

Date
Issued

Risk Management and

Incident Investigation
Framo
Others
Others
Others
Others

Page 2 of 3

Valid
Until

APPLICATION FORM
STCW CERTIFICATES 78/95 - OFFICERS
Certificates

Number

Place issued

Proficiency in Survival Craft and Rescue

1 Boats other than fast rescue boats
2
3
4
5
6
7

Date
Issued

Valid
Until

Regulations
A - VI/2 Para 1 to 4

Fast Rescue Boats

Advanced-Fire Fighting
Medical Care
Maritime English
Radar Simulator

A-VI/3
A - VI/4 Para 4-2
A-II/1; A-II/2
A - II/1,2 acc. To Sec. BI/12p.1
A-II/1,2 acc. to Sec. BI/12para.2 to17

Radar Observer and Plotting

Radar ARPA, Bridge TeamWork and Search

8 and Rescue management level

A-I/12 and A-II/2

9 Ship Safety Officer

Ship Security Officer
10

SOLAS Ch XI/2- ISPS

Code Sect A-13/2

11
12
13
14
15
16

Oil Tanker Familiarization

Advanced Training on Oil Tanker
OperationsTanker Familiarization
Chemical
Specialized Training for Chemical Tankers
Liquefied Gas Tanker Familiarization
Specialized Training for Liquefied Gas
Tankers
Operartional
Use of Electronic Chart
17
Display and information System (ECDIS )
18 Inert Gas Systems (IGS)
Transport and Handling Dangerous
19
Hazardous and Harmful Cargoes
20 Ship Safety Officer
21 Personal Survival Techniques
22 Crude oil washing (COW)
Personal Safety and Social Responsibilities
23
on board ships

A-V/1para.1 to 7
A-V/1para.8 to 14
A-V/1para.1 to 7
A-V/1,para.15 to 21
A-V/1,p.1 to 7
A-V/1,para. 22- 34
A-II/1; A-II/2

Prevention of Pollution of the Maritime

24 Environment
25 Ship Handling and Maneuvring Simulation
26 General Operator for GMDSS (GOC)
27 Bridge Team and Resource Management
Tanker Management and self-assesement
28

A-II/1; A-II/2; A-III/1; AIII/2

29 Washing of oil tankers cargo holds

A-V/1para.12
A-II/1; A-II/2
A-VI/5
A-VI/1 para 2.1.1.1
A-V/1para.12
A-VI/1 para 2.1.1.4

No expiry
date

A-II/1; A-II/6
A-IV/2
A-VIII/1 and A-VIII/2
TMSA-OCIMF/2004
Guide and ISM Code
MARPOL-73/78

VESSEL

Position

From
Months

PREVIOUS SEA SERVICE( please start with the latest )

To
Reason
Type
Days
GRT

Engine
KW

Pls state the vessel where you have obtained experience on the following:
Vetting Inspections/CDI : (specify companies)
QA+ISM Experience:
Cargoes Carried:
References:(Pls state last 3 shipmanagement companies with tel no.)
I herewith certify that the above information is true and accurate to the best of my ability and that no certificate of competence or licence issued to me
has ever been revoked or suspended. I understand that previuos employers may be asked for information concerning my employment record with
them and I hereby release from all liability or damage those individuals or companies who provide such information.

Signature:

Date:

Page 3 of 3

Owner
Crew Agent

Flag
Built