SEA POSITION APPLICATION FORM

Present rank Rank applied for Date

NAUTICAL GRADUATE DECK CADET

Name in full (First, Middle, Last) Nationality

PROSPER, MAN-NYABA, MAHAMI GHANAIAN
Date of birth Age Height Place and Country of birth
21 183CM GHANA

Hair color Eye color Weight Married Single

BLACK BROWN 70KG Divorced Widower / Widow
Nearest airport Next of kin
KOTOKA INTERNETIONAL AIRPORT Name: MAHAMI TIA MANDIAAYA
Permanent / contact address Relationship: BROTHER
GHANA, TAMALE ZY 148
Address: REGIONAL MARITIME
UNIVERSITY, GP115 GHANA

For contact numbers please include international dialing code

Telephone number Mobile number Email address
+233244434061 +233509876952 Tiamahami@yahoo.com
Passport Passport Passport Issue Passport
Nationality Number Date Expiry Date
GHANA
Seaman’s Book Seaman Book Seaman Book Seaman Book
Nationality Number Issue Date Expiry Date
GHANA DBN003192

If accepted, date available for service: U.S. Visa Type Valid until
dd/mm/yyyy             dd/mm/yyyy
Medical certificate expiry date: Other Visa Type Valid until
            dd/mm/yyyy

Yellow fever vaccination expiry date: Other Visa Type Valid until
LIFE TIME             dd/mm/yyyy
Professional Qualifications

Licenses Grade of Number Date issued Place issued / Expiry date

license revalidated
National 000900 NO dd/mm/yyyy
(please state)
NAUTICAL
SCIENCE
Bahamas Flag             dd/mm/yyyy       dd/mm/yyyy

TEEKAY TANKERS APPLICATION FORM AND EXPERIENCE RECORD ─ DOC Version 01 Date: 21st Feb 2020 1
 State
     

TEEKAY TANKERS APPLICATION FORM AND EXPERIENCE RECORD ─ DOC NO: MARINE HR TKG - 51 2
Previous Sea Experience
Vessel name Flag Deck Engine Vessel type Full company name Rank Period Months / Days
Trading area/ Type & BHP From – To
Deadweight

Last                                                       /      
     
nd
2 Last                                                       /      
     
rd
3 Last                                                       /      
     
th
4 Last                                                       /      
     
th
5 Last                                                       /      
     
th
6 Last                                                       /      
     
th
7 Last                                                       /      
     
th
8 Last                                                       /      
     
th
9 Last                                                       /      
     
th
10 Last                                                       /      
     
th
11 Last                                                       /      
     

TEEKAY TANKERS APPLICATION FORM AND EXPERIENCE RECORD ─ DOC NO: MARINE HR TKG - 51 3
 Vessel name Flag Deck Engine Vessel type Full company name Rank Period Months / Days
Trading area/ Type & BHP From – To
Deadweight

12th Last                                                       /      
     
13th Last                                                       /      
     
14th Last                                                       /      
     
15th Last                                                       /      
     
Other experiences (new buildings / dry docks / repair yards / office secondments, etc.)

➢ Under supervision Communicated with vessels at port, department and at anchorage.

➢ Performed administrative duties
➢ logged keeping for tugboats movement and vessels movement.
➢ Cleaning of the deck areas and Assisted with mooring operations under supervision.

Please complete the attached form electronically (you can type directly in the fields provided) and send to the below e-mail:
Indian National: OfficeIndia@teekay.com
Philippine National: ConventionalRecruit.PH@teekay.com
All Other Nationalities: ConventionalRecruit.SG@teekay.com

References: Name, company and contact telephone number

1) CAPT. JAMAL TABBICCA, REGIONAL MARITIME UNIVERSITY 2) CAPT. FRANCIS K.B. MICAH, GHANA PORTS AND HARBOR
AND +233544341380 AUTHORITY AND +233244167488

TEEKAY TANKERS APPLICATION FORM AND EXPERIENCE RECORD ─ DOC NO: MARINE HR TKG - 51 4
 Marine course attended Date attended Expiry (if any)
Basic Fire Fighting

Advanced Fire Fighting dd/mm/yyyy dd/mm/yyyy

Basic Survival At Sea

Elementary First Aid

Medical First Aid dd/mm/yyyy dd/mm/yyyy

Proficiency in Medical Care Onboard Ship dd/mm/yyyy dd/mm/yyyy
Certificate of Proficiency in Survival Craft dd/mm/yyyy dd/mm/yyyy
Personal Safety & Social Responsibility

Basic Oil Tanker Training

Advanced / Specialized Oil Tanker Training dd/mm/yyyy dd/mm/yyyy

Navigation, Radar & ARPA Training (Operational Level) dd/mm/yyyy dd/mm/yyyy
Navigation, Radar & ARPA Training (Advanced Level) dd/mm/yyyy dd/mm/yyyy
Electronic Chart Display & Information System (Generic) dd/mm/yyyy dd/mm/yyyy
ECDIS – FURUNO Type ( ) dd/mm/yyyy dd/mm/yyyy
ECDIS – JRC Type ( ) dd/mm/yyyy dd/mm/yyyy
Ship Handling Simulator Course dd/mm/yyyy dd/mm/yyyy
Engine Room Simulator Course dd/mm/yyyy dd/mm/yyyy
Bridge Team Management Course dd/mm/yyyy dd/mm/yyyy
Engine Team Management Course dd/mm/yyyy dd/mm/yyyy
Ship Safety Officer Course dd/mm/yyyy dd/mm/yyyy
Ship Security Officer Course dd/mm/yyyy dd/mm/yyyy
Efficient Deck Hand dd/mm/yyyy dd/mm/yyyy
Welding Course dd/mm/yyyy dd/mm/yyyy
Fast Rescue Boat dd/mm/yyyy dd/mm/yyyy
Incident Investigation Course dd/mm/yyyy dd/mm/yyyy
Assessor Training dd/mm/yyyy dd/mm/yyyy
ICE Navigation dd/mm/yyyy dd/mm/yyyy
Liquid Cargo Handling Simulator dd/mm/yyyy dd/mm/yyyy
GMDSS GOC dd/mm/yyyy dd/mm/yyyy
GMDSS Endorsement dd/mm/yyyy dd/mm/yyyy
Oil Tanker Endorsement (Level……………………………………) dd/mm/yyyy dd/mm/yyyy
High Voltage Course (Level………………………………………..) dd/mm/yyyy dd/mm/yyyy
I grant consent to Teekay to process personal information lawfully, fairly and in a transparent manner in accordance with
data protection principle and in compliance with General Data Protection Regulation (GDPR) referred in  Teekay
Personal Information Privacy Policy (PL0128). 

TEEKAY TANKERS APPLICATION FORM AND EXPERIENCE RECORD ─ DOC NO: MARINE HR TKG - 51 5
 Signature:

TEEKAY TANKERS APPLICATION FORM AND EXPERIENCE RECORD ─ DOC NO: MARINE HR TKG - 51 6