General information

Family name *
Christian name *
Fathers name *
Mothers name *
Date/Place of birth
License nr./Grade *
Other licenses
US C1/D Visa expire
ID code
Marital status	married single devorced widower
Children (name/DOB)
Home address *
Tel *
Mob
E-mail *
Next of kin name/address
English language knowledge *	moderate good excellent
Speak other languages

Seaman's book		Exp.
Country		Height
Seaman's passport *		Exp.
Port		Width
International p.port *		Exp.
Country		Clothes/shoes

Education *

I. M. O. Licenses

Endorsement of License		Exp
STCW RULES
A R P A Certificate		Exp
Radar Observation & Plotting		Exp
G.M.D.S.S. Certificate		Iss
Endorsement exp
STCW’78/95 – (A-VI/1) - Basic		Exp
Advanced Fire Fighting (A-VI/3)		Exp
Carrying Dangerous & Hazardous Cargoes (B-V/4,5)		Exp
Bridge Team Management		Exp
First aid (medical care) (A-VI/4-1,2)		Exp
Proficiency in Survival Craft (A-VI/2)		Exp
Maintenance of electrical & electronic equipment		Exp
Compressed air breathing-apparatus		Exp
Certificate for RO/RO passenger vessel		Exp
Passenger Ship Crowd Management Training		Exp
Passenger Ship Passenger Safety Training		Exp
Passenger Ship Crisis Management Training		Exp
Passenger Ship Familiarization Training		Exp
Passenger Ship Safety Training		Exp
Ship’s Safety Officer		Exp
Medical Fitness Certificate		Exp
Yellow Fever Vaccination		Exp
Other Licenses
		Exp.
		Exp.
		Exp.
		Exp.
		Exp.

SEA SERVICE (last five years):

Total years of service
Expected min wage, usd *

Place of employment #1: Vessels name RANK FM/TO GRT Engine BHP Aux Engine Kind of Automatic Kind of refsystem Quantity of passengers Kind of work FLAG / Built Reason of discharge Crew Agency Principal Company

Place of employment #2: Vessels name RANK FM/TO GRT Engine BHP Aux Engine Kind of Automatic Kind of refsystem Quantity of passengers Kind of work FLAG / Built Reason of discharge Crew Agency Principal Company

REFERENCES

VESSEL
SHIPOWNER / SHIPMANAGER NAME / ADDRESS
CONTACT PERSON
TEL No.
FAX No.
E-mail
VESSEL
SHIPOWNER / SHIPMANAGER NAME / ADDRESS
CONTACT PERSON
TEL No.
FAX No.
E-mail
VESSEL
SHIPOWNER / SHIPMANAGER NAME / ADDRESS
CONTACT PERSON
TEL No.
FAX No.
E-mail
DATE OF SIGNING