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TRANS W SHIPPING APPLICANT’S PERSONAL DATA

POSITION APPLIED FOR: PHOTO:
FIRST NAME*:LAST NAME*:
FATHER’S NAME*:CITIZENSHIP:
DATE OF BIRTH:ADDRESS (incl. post code)
PLACE OF BIRTH:PHONE:
E-MAIL:
MARITAL STATUS:
IF MARRIED:
DATE OF MARRIAGE: NEXT OF KIN:
WIFE’S FIRST / LAST NAME: RELATION:
FATHER’S NAME: FIRST / LAST NAME:
WIFE’S DATE OF BIRTH: FATHER’S NAME:
ADDRESS: ADDRESS:
PHONE: PHONE:

CHILDREN (IF APPLICABLE):

FIRST/ LAST NAME:DATE OF BIRTH:
CLOTHES SIZES:
OVERALL
SAFETY SHOES HEIGHT
TROUSERS WEIGHT
SWEATER COLOR OF EYES
SHIRT COLOR OF HAIR

MARINE EDUCATION RECEIVED

NAME OF SCHOOLFROMTILLTYPE OF DEGREE RECEIVED

NATIONAL DOCUMENTS (RUSSIAN)

PASSPORT / SBKNO.ISSUEDVALID
SEAMAN’S PASSPORT
TRAVELLING PASSPORT
GRADENO.ISSUEDVALID
NAT.LICENCE*:
ENDORSEMENT: OIL Chem LPG
GMDSS:
ENDORSEMENT:
RADAR OBSERVER:IMO RES. A483 (XII)
ARPA:IMO RES. A482 (XII)
CERTIFICATESTCW CODENOISSUEDVAILD TILL
BASIC SAFETY STCW ‘95
PERS. SAFETY AND SOCIAL RESPONS.:A-V1/1-4
ADVANCED FIRE FIGHTING:A-V1/3
SURVIVAL CRAFT, RESCUE BOATS:A-V1/2-1
MEDICAL EMERGENCY FIRST AIDA-V1/4-1
MEDICAL CARE CERTIF.A-V1/4-2
HAZMATB-V/4, B-V/5
HAZMAT (USA-TITLE 49)
OIL TANKER /SPECIALIZED/ PROGR.A-V/1, P.9-14
OIL TANKER /FAMILIARIZATION/ PROGR.A-V/1, P.2-7
CHEM TANKER /SPECIALIZED/ PROGR.A-V/1, P.16-21
CHEM TANKER /FAMILIARIZATION/ PROGR.A-V/1, P.2-7
LIQUID GAS TANK /SPECIALIZED/ PROGR.A-V/1, P.23-34
LIQUID GAS TANK /FAMILIARIZATION/ PROGR.A-V/1, P.2-7
CRUDE OIL WASHING OPERATIONS/INERT GAS SYSTEM
HEALTH CERTIFICATE
YELLOW FEVER

ENGLISH KNOWLEDGE

EXCELLENTGOODMODERATESATISFACTORYPOOR

USA VISA (IF VALID)

PLACE OF ISSUE (CITY)FROMVALID TILL

FLAGS DOCUMENTS

LIBERIANGRADENBRISSUEDTILLPANAMANIANGRADENBRISSUEDTILL
SBKSBK
LICENSELICENSE
GMDSSGMDSS
SPECIAL CERTIFICATESSPECIAL CERTIFICATES
NISDUTCH
SBKSBK
LICENSELICENSE
GMDSSGMDSS
SPECIAL CERTIFICATESSPECIAL CERTIFICATES
GERMANANT&BARBUDA
SBKSBK
LICENSE
CYPRUS
SBK
LICENSE

OTHER DOCUMENTS (NOT MENTIONED BEFORE)

DOCUMENTGRADENO.ISSUEDVALID

SEA SERVICE LAST 10 YEARS

VESSEL’S NAMECOMPANY
(SHIP’S OWNER OR SHIP’S MANAGER)
FLAGGRT*VSL’S TYPE*ENG. TYPEHPRANKEPLOY M/YMENT M/YTOTAL M

SHIP OWNER’S DATA

COMPANYTEL/FAXCONTACT PERSON

CREW AGENCIES DATA

VESSELCREW AGENCYTEL/FAX CONTACT PERSON

С автоматизированной обработкой моих персональных данных, указанных в анкете, их передачей третьим лицам (включая трансграничную) и хранением в целях трудоустройства в соответствии с Федеральным законом РФ N 152-Ф3 согласен, что подтверждаю заполнением и отправкой настоящей Анкеты - Application Form. Также подтверждаю, что мои персональные данные являются общедоступными.

DATE : SIGNATURE OF SEAMAN :