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
Tanker Familiarization Course (A-V/I)		Exp
Oil Tanker Specialized Training (A-V/1)		Exp
Crude Oil Washing (A-V/1) (COW)		Exp
Inert Gas Training (A-V/1) (IGS)		Exp
Chemical and Liquefied Gas Tankers (A-V/I)		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 / Vessels type RANK FM/TO DWT Gear on deck Main Eng. Builder / Model BHP Auxiliary Engine BUilder / Model Auxiliary Engine Number / HP / KW Kind of Automatic Kind of refsystem Kind of cargo FLAG / Built Reason of discharge Crew Agency Principal Company

Place of employment #2: Vessels name / Vessels type RANK FM/TO DWT Gear on deck Main Eng. Builder / Model BHP Auxiliary Engine BUilder / Model Auxiliary Engine Number / HP / KW Kind of Automatic Kind of refsystem Kind of cargo 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