REMARKS: DESIRED WAGE:
COVID-19 VACCINATION STATUS:
POSITION TO APPLY FOR
SURNAME / NAME / MIDDLE
NATIONALITY
DATE / PLACE OF BIRTH
HEIGHT / WEIGHT
CLOTHES / FOOTWEAR SIZE
PHONE / MOBILE NO.
E-Mail
ADDRESS
YES ☐
YES ☐ HOW MANY
MARITAL STATUS CHILDREN UNDER 18
MARRIED
NO ☐ YRS OLD?
NO ☐
NAME:
NEXT OF KIN RELATION
TEL. No.:
Mother’s full name: Father’s full name:
CIVIL PASSP NO. ISSUED
SEAMAN'S PASSP NO. ISSUED
SEAMAN'S BOOK NO. ISSUED
USA VISA NO. ISSUED
ENGLISH ABILITY FLUENT ☐ VERY GOOD ☐ GOOD ☐ FAIR ☐
DETAILS OF LICENSES / CERTIFICATES ( NATIONAL FIRST )
CERTIFICATE NUMBER GRADE ISSUED EXPIRES PLACE OF
ISSUE
CERTIFICATE OF
COMPETENCY
ENDORSEMENT (if any)
FLAG STATE
ENDORSEMENT (if any)
FLAG STATE
ENDORSEMENT (if any)
ADDITIONAL COURSES NUMBER ISSUED EXPIRES
STCW BASIC (A-VI/1)
PROFICIENCY IN SURVIVAL CRAFT (A-VI/2)
PROFICIENCY IN FASTRESCUE BOAT (A-VI/2-2)
SHIP'S SECURITY OFFICER
ADVANCED FIRE FIGHTING (A-VI/3)
DANGEROUS & HAZARDOUS (B-V/b),(B-V/c)
GMDSS
GMDSS ENDORSEMENT
DESIGNATED SECURITY DUTIES
ARPA
MEDICAL FIRST AID
MEDICAL CARE ON BOARD SHIP
BRIDGE TEAM AND RESOURCE
MANAGEMENT
ENGINE ROOM RESOURCE MANAGEMENT
AND TEAMWORK
MONITORING OF THE MAIN AND AUXILIARY
MACHINERY OPERATION AND ASSOCIATED
CONTROL SYSTEMS
ECDIS
MARINE ENVIRONMENTAL AWARENESS
YELLOW FEVER
MEDICAL CERTIFICATE
ACADEMY / INSTITUTE WHERE LICENSE WAS OBTAINED
APPLICATION FORM Page: 2 of 2
PREVIOUS SEA SERVICE
OWNERS/
VESSEL TYPE/GT ENGINE/HP FLAG RANK S/ON S/OFF
MANAGERS
REASONS FOR LEAVING THE PREVIOUS EMPLOYER
Employer name Reason for leaving
INTERVIEW INFORMATION – To be completed by the interviewer
Interview date: Interviewed by: Result:
Attitude towards
English level: First impression:
Eleen Marine:
Remarks:
☒ By checking this box, I agree that:
1. The above information is true and accurate to the best of my ability;
2. No Certificate of Competency or license issued to me has ever been revoked or suspended;
3. Previous Employers may be asked for information, concerning my employment record and I hereby release from all
liability or damage those individuals or companies who provide such information.
☒ By checking this box, I confirm my legal age, legal capacity, and consent to the processing of my personal data in
accordance with GDPR regulations.
Date:
SIGN: __________________
