Application form – example

1.0 Rank ABLE SEAMAN (WELDER)

2. SEAMAN’S PERSONAL INFORMATION

2.1 Last name Petrov
2.2 First name Petr
2.3 Father’s name Ivan
2.4 Nationality Russian
2.5 Marital status Married
2.6 Date of Birth 01-01-1980
2.7 Place of Birth Kaliningrad
2.8 Address Kaliningrad, Morkaya Str. 115-1, 236000
2.9 Contact Numbers 8 900 000 000
2.10 E-mail petrovpetr@pochta.ru
2.11 Maritime English level Good

3. SEAMAN’S DOCUMENTS

3.1 Seaman Passport (УЛМ)  
  Number 1234567
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date 31-12-2024
3.2 Travelling Passport  
  Number 123 456 789
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date 01-01-2029
3.3 National Passport  
  Number 1234567890
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date  

4. SEAMAN’S LICENCES

4.1 Certificate of Competency  
  Rank ABLE SEAMAN II/5
  Number KGD123456789
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date  
4.2 GMDSS (Master/COF)  
  Rank  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  

5. SEAMAN’S CERTIFICATES

5.1 Basic Safety  
  Number 1234567
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date 01-01-2024
5.2 Proficiency in Survival Craft  
  Number 1234567
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date 01-01-2024
5.3 Designated Security Duties  
  Number 1234567
  Nationality RUS
  Issue Date 01-01-2019
  Expiry Date 01-01-2024
5.4 Medical First Aid  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.5 Advanced Fire Fighting  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.6 BRM/ERM  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.7 Radar Observer Plotting  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.8 ARPA  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.9 Ship Security Officer  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.10 Medical Care  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.11 Dangerous goods  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.12 ECDIS  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  
5.13 ECDIS JRC  
  Number  
  Nationality  
  Issue Date  
  Expiry Date  

6. VISA

6.1 Schengen visa Yes
  Type C
  Nationality POLAND
  Issue Date 01-01-2019
  Expiry Date 31-12-2020

7. HEALTH CERTIFICATE

7.1 Issue Date 01-01-2019
  Expiry Date 01-01-2020
7.2 Last colour vision test 01-01-2019

DATE WHEN READY FOR SAILING

11-06-2019

8. PREVIOUS SEA SERVICE (for the last 5 years)

Vessel name: ANMI
Flag: Bahamas
Rank: AB
Company: Misje Rederi AS
Vessеl Type: General Cargo
Engine Type (BHP): Caterpillar type 3606Dita 1499kW
GRT/DWT: 2373/4245
Sign-On Date: 01-10-2018
Sign-Off Date: 31-12-2018
Sign-Off Reason: End of contract

9. SEAMAN’S EDUCATION

9.1 Education/Training Courses/Other Courses Welder course

10. NEXT OF KIN

10.1 Name Petrova Victoria
10.2 Relation Wife
10.3 Contact Numbers 89000000000
10.4 Address Kaliningrad, Morskaya Str. 115-1, 236000

11. ADDITIONAL INFORMATION

11.1 Clothes Size 50
11.2 Head Size 52
11.3 Foot Size 43
11.4 Height 185 cm
11.5 Weight 85 kg
11.6 Colour of Eyes Blue
11.7 Colour of Hair Brown
11.8 Blood Type A(II)

12. REFERENCES, PAST EMPLOYER

Name of company: Misje Rederi AS
Person to contact: Margarita
Address: Kalininfrad, Teatralnaya Str. 30-312
Phone: 8 (4012) 612208