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VII. Fill in the application form

PERSONAL APPLICATION FORM

Position applied for

Personal Details

Surname

First name(s)

Portrait Photo of Applicant

Date of Birth

Place of Birth

Nationality

Marital Status

Sex

Children

Shoe Size

Weight

Height

Overall size

Address

City / Country

Phone

Nearest Airport

Mobile phone

Next of kin

Relationship

Address/Contact

National Documents

Name of Maritime Training Institute

No.

Date / Place of issue

Expiry Date

Passport

Seaman’s Book

US Visa

CoC:

GOC (GMDSS) (IV/2)

Basic Safety Training (VI/1)

Survival Craft (VI/2)

Advanced Fire Fighting (VI/3)

Medical Care (VI/4)

Tanker Familiarization (V/1)

Advanced Oil (V/1)

Advanced Chemical (V/1)

Advanced Gas (V/1)

Ship Security Officer

Inert Gas System Operations

Crude Oil Washing

Bridge Team Management

Safety Management System

Operation of Electrical and Electronic Control Equipment

Carrying Dangerous and Hazardous Cargoes

Radar & ARPA

Yellow Fever Vaccination

Personal Skills

Excellent

Very Good.

Good

Poor

Fair

Remarks

Command of English language

Computer literacy

Other

Super-statutory training

Flag State Documents / Endorsements

Enter No. and Exp. Date

Liberia

Cayman Island

Marshal Island

Germany

Seaman’s Book

CoC:

Basic Safety Training (VI/1)

Survival Craft (VI/2)

Advanced Fire Fighting (VI/3)

Medical Care (VI/4)

GOC (GMDSS) (IV/2)

Tanker Familiarization (V/1)

Advanced Oil (V/1)

Advanced Chemical (V/1)

Advanced Gas (V/1)

Sea Service (from latest to previous)

Name of Vessel

Position

Vessel Type

DWT

Eng. Type

BHP

Year Built

Flag

Manager / Crew Agent

from

to

References (state previous ship manager(s) including address, phone and person in charge):

Above information is to the best of my knowledge correct. (to be signed by the person, who completed the form)

Date

Name in Print

Signature