PERSONAL PROFILE AND HISTORY OF EMPLOYMENT
Rank: Surname: Forenames:
Nationality: Date of Birth: Place of Birth:
Home Address: Tel. No: Fax No:
Mobile No: E-mail:
Nearest Alternative
Airport: Airport:
Marital Children (Please include Date of Birth.):
Status:
Next of Kin* Address Tel. No:
Name &
(if different to
Relationship
above): Other..
Sea Service
Vessel Name: Flag: GRT HP Vessel Engine Rank From To Ship Manager/
type type Owner
Experience with mixed Nationalities:
Nationality crew: Yes/No
Height (Mtr/cm) Frame Size (S, M, L)
Weight (KG) Any Distinguishing Marks
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PERSONAL PROFILE AND HISTORY OF EMPLOYMENT
DOCUMENT NUMBER ISSUED AT ISSUED ON DATE OF
EXPIRY
LICENCE / CERTIFICATE Grade Number
National
LICENCE / CERTIFICATE
Others (please specify)
STCW ENDORSEMENT
GMDSS (GOC) CERT
MEDICAL CERTIFICATE
SEAMAN’S BOOK
PASSPORT
RADAR SIMULATOR CERT
ARPA COURSE
FIRE FIGHTING CERT
FIRST AID CERTIFICATE
PERSONAL SURVIVAL
PERSONAL SAFETY & SOCIAL
RESPONSIBILITIES
SURVIVAL CRAFT
PILOTAGE EXEMPTIONS
DRIVERS LICENCE
LANGUAGES
CRANE EXPERIENCE :
YES / NO
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PERSONAL PROFILE AND HISTORY OF EMPLOYMENT
REFERENCES
1. COMPANY NAME & ……………………………………………….
TELEPHONE NUMBER
……………………………………………….
2. COMPANY NAME & ………………………………………………..
TELEPHONE NUMBER
………………………………………………..
ANY OTHER
RELEVENT INFORMATION
I hearby declare that all information given is herein correct and all certificates listed are genuine and
re-validated to STCW 95:
NB: By signing and submitting this document you consent to Mainprize Offshore Limited holding
this information for the purpose of possible employment under: General Data Protection
Regulations (GDPR), should you wish to have them removed at a later date please email
info@mainprizeoffshore.co.uk we will delete and send a confirmation email.
DATE: SIGNED:
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