17 Machtovaya str,Odessa, 65010, Ukraine Tel: +380482329204 e-mail:
[email protected] www.AlphaNavigation.com
APPLICATION FORM В
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Position Applied for
Date available
Surname
Marital Status
Name
Father's Name
photo
Middle Name
birthdate
Date of Birth / Place
Mother's Name
Nationality
birthdate
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П
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*Contact phone *Private phone
Mailing Address zip/postal
Facebook
City
Region
Country
Email Next of kin Relation
Mailing Address zip/postal
Phone
Country
Child's Name:
Child's Name:
Child's Name:
Date of Birth
Date of Birth
Date of Birth
Last 7 years Sea Service Data (Fill in block letters) Vessel's name / Flag / Shipowner's name / Country
<-- Latest
City
Region
Rank
From (D/M/Y)
Vessel's Type
DWT
Engine Type
Crewing Agency
Till(D/M/Y)
TEU (CONT only)
GRT
HP
Salary
1 Reason of break:
Crane Type & Brand (AB & Bosun):
2 Reason of break:
Crane Type & Brand (AB & Bosun):
3 Reason of break:
Crane Type & Brand (AB & Bosun):
4 Reason of break:
Crane Type & Brand (AB & Bosun):
5 Reason of break:
Crane Type & Brand (AB & Bosun):
6 Reason of break:
Crane Type & Brand (AB & Bosun):
7 Reason of break:
Crane Type & Brand (AB & Bosun):
8 Reason of break:
Crane Type & Brand (AB & Bosun):
9 Reason of break:
Crane Type & Brand (AB & Bosun):
Past
10 Reason of break:
Crane Type & Brand (AB & Bosun):
School
Education
Number
Passport/License Foreign Civil Passport
Date Issued
From
Till
Place Issued
Valid untill
Philippines
National Seaman’s Book
Ukraine
Seaman's book
Philippines
Seaman's book
country
National CoC
grade:
Endorsment National CoC
grade:
Endorsment Foreign Flag License
country
Foreign Flag License
country
USA Visa C1/D
Operational Procedures OP-01
Annex 5 Application Form
Revision 0 30.01.2013
Pages 2
17 Machtovaya str,Odessa, 65010, Ukraine Tel: +380482329204 e-mail:
[email protected] www.AlphaNavigation.com
Certificates
Number
Date Issued
Place Issued
Valid untill
[Section A-VI/1 STCW-CODE’95] Basic safety course [Section A-VI/2 STCW-CODE’95] Proficiency in survival craft [Section A-VI/3 STCW-CODE’95] Advanced fire fighting [Section A-VI/4-1 STCW-CODE’95] Medical first aid [Section A-VI/4 STCW-CODE’95] Medical care [Section B-V/4&B-V/5 STCW-CODE’95] Hazardous Cargoes [Reg. V/1, prg.1.1, 1.2; Section A-V/1, prg.1-7 STCW-CODE’95] Oil Tankers Familiarization [Res.10 Section A-V/1, prg.9-14] Advanced training on oil tankers [Reg. V/1, prg.1.1, 1.2; Section A-V/1, prg.1-7 STCW-CODE’95] Chemical Tankers Familiarization [Res.11,12 Section A-V/1, prg.16-34] Advanced training on chemical tankers [Reg. V/1, prg.1.1, 1.2; Section A-V/1, prg.1-7 STCW-CODE’95] Liquefied gas Tankers Familiarization [Res.11,12 Section A-V/1, prg.16-34] Advanced training on liquefied gas tankers
MARPOL 73/78 (Crude Oil Washing) Inert gas system Security officer certificate (ISPC Code) [Section II/2 STCW-CODE'95] Refreshing and updating (Revalidation Course) Bridge Team Management / Engine Team Management ECDIS Large ship's Handling Breathing apparatus Electronic and electrical maintenance Ship's security for ratings Radar Observing Certificate ARPA Certificate GMDSS Certificate Endorsement Health List (Medical Certificate) Drug Alcohol Test Yellow Fever Vaccination Card English test certificate (Licensed by Marlins or CES) Multy Schengen Visa Crane Certificate Other certificates
Other Important Information Shipowner's Full Style of LAST THREE VESSELS
(NOT THE MANNING AGENT) Tel /Fax
Vessel's name / Shipowner's name
Person in charge
3 4 3
(NOT THE MANNING AGENT)
Reference from previous crew for the last two vessels
Cellphone number
Name with Rank
Address
1 2 3 4
Applicant’s Weight, Height, Sizes, Special Peculiarities Weight, kg
Height, cm
English level
Overall size
Shoes size
Fluent
Good
Satisfactory
Do you Smoke?
Yes
No
How many per day? _____________________________
Do you Drink Alcohol?
Yes
No
Did you go in for sports?
Often
YES
NO
Poor
Hair
Eyes
Other Languages
occasional
Specify _____________________________________
Please advise what kind of sports:
I hereby affirm that all the information provided by me in this FORM is TRUE and CORRECT to the best of my knowledge.
Manager:
Date:
Seafarer's signature:
Checked by: Staff
Operational Procedures OP-01
Annex 5 Application Form
Facebook Site
Revision 0 30.01.2013
CLICK TO SEND FORM
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