NordOst Marine Company
Office 2, 32 Novoselskogo Str., Odessa Ukraine
Tel.: +380 (48) 723-00-70; fax. +380 (48) 723-00-71;
mob.; +380 (93) 576-26-26; +380 (95) 576-26-26; +380 (97) 576-26-26
e-mail: cv@nordostmarine.com
SEAMAN’S EMPLOYMENT APPLICATION FORM
Position applied for: Available from:
Second choice (if any): Last salary:
Photo
First and family name:
Personal particulars
Date of birth: Place of birth: Nationality:
Marital status: Color of hair: Color of eyes:
Height (cm): Weight (kg): Size: Shoes:
Name of father: Name of mother: Name of spouse:
Children under 18 (name/date of birth):
Home address:
Telephone:
E-mail:
Next of Kin: Surname: Name: Relationship:
Address: Telephone:
Special Remarks (only for office use)
English: Marlins Test: _____ % CES Test: _____% Other: ________________________________
Initial assessment of applicant for further recruitment
Comment:
_________________________________________________________________________________________________
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_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Signature of manager: Date:
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NordOst Marine Company
Office 2, 32 Novoselskogo Str., Odessa Ukraine
Tel.: +380 (48) 723-00-70; fax. +380 (48) 723-00-71;
mob.; +380 (93) 576-26-26; +380 (95) 576-26-26; +380 (97) 576-26-26
e-mail: cv@nordostmarine.com
Documents and certificates
Passports No. Place of issue Date of issue Valid until
Seaman’s passport
Biometric passport
National passport ID №
Other foreign passport
Schengen Visa
USA C1/D visa
Diplomas Grade No. Place of issue Date of issue Valid until
Certificate of Competency
Endorsement
GMDSS CoC
GMDSS Endorsement
Name of Marine School (Academy): Graduated:
STCW Certificates No Date of issue Valid until
Safety familiarization, basic safety training and
instructions for all seafarers
Firefighting and prevention
Advanced fire-fighting
Medical fitness certificate
Elementary first aid
Medical first aid
Medical care
Proficiency in survival craft and rescue boats other that
fast rescue boats
RADAR & ARPA simulator management level
A.R.P.A. operation level
Ship Security officer
ECDIS
ROPS, ARPA
Dangerous cargo (Hazmat)
Yellow fever
Security training for seafarers with designated security
duties
Security awareness training for all seafarers
Please answer the following questions:
● Did you suffer, or presently suffer from, any disease likely to render you unfit for services at sea or YES NO
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NordOst Marine Company
Office 2, 32 Novoselskogo Str., Odessa Ukraine
Tel.: +380 (48) 723-00-70; fax. +380 (48) 723-00-71;
mob.; +380 (93) 576-26-26; +380 (95) 576-26-26; +380 (97) 576-26-26
e-mail: cv@nordostmarine.com
likely to endanger the health of other persons on board?
If yes, please provide details:
● Did you suffer any accident, which rendered you temporary and/or partially disabled? YES NO
● Did you ever undergo psychiatric treatment? YES NO
● Are you addicted to alcohol or drugs of any kind? YES NO
I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any
vessel on which I may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated
company of the Managers (together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein,
or provided to any of the Companies at a later date, including with respect to personal and pensions administration, employee management and as
required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be
stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above
may involve the transfer of my personal data within the Managers’ organization.
Настоящим заявляю, что приведенные выше факты и информация являются достоверными и точными. Я также даю согласие на владение и
обработку (i) владельцами любого судна, на которое я могу время от времени назначаться, и (ii) менеджерами и любыми прямыми или
косвенными материнскими, или дочерними, или ассоциированными, или аффилированными компаниями управляющих ( вместе именуемые
«Компании») в целях моей занятости, персональных данных обо мне, содержащихся здесь, или предоставленных любой из Компаний на
более позднем этапе, в том числе в отношении управления персоналом и пенсий, управления сотрудниками и по мере необходимости
соблюдать любые законы, правила или контракты, применимые к любой из компаний или их предприятий. Я понимаю, что эти данные будут
храниться в базе данных менеджеров в целях моей текущей или будущей работы, организованной менеджерами. Кроме того, я
подтверждаю, что вышеизложенное может включать передачу моих персональных данных в организации Управляющих.
Signature _____________________________ Date __________________
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APPLICATION FOR EMPLOYMENT
Sea Experience : (List the most recent experience first; use additional sheets as required)
Vessel’s Reason for
Rank Main Engine (2) BHP Ship-owner/ Manager Manager From To
Name Flag Type (1) GRT DWT S/off (3)
(1)
Use only the following abbreviations for vsl types:
*Please use only following abbreviations for the vessel type: (2)
GCD General Cargo MLP Multi-Purpose B/C Bulk Carrier CON Container O/O Ore Oil Engineers to give make/model of engines, e.g.
OBO Ore/Bulk/Oil “MAN 14V52/55A” or “SULZER 5RTA58”
(3)
TNC Tanker Crude TNP Tanker Product TNV VLCC/ULCC CHM Chemical Tanker LPG/LNG Gas Reason of Sing Off, e.g. “EOC – End of Contract”,
Tanker FSO / FPSO “MED – Medical Ground”, “OWN – Own
PAS Passenger Ship R/O Ro/Ro DRG Dredger NVL Naval Ship H/L Heavy Lift
OSV Offshore Supply SRV Survey vessel LOG Log/Timber SSHL Semi-Submergible MOB Mobile
request”
Offshore Unit Please provide details of two recent employers who we may contact for references
Name of Company:
Name of person to contact:
Address:
Telephone/E-Mail:
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