Форма регистрации моряков

Crew Application Form

Position Applied For

Manning Office

Requested Wages

Date of Availability

PART I. PERSONAL DESCRIPTION AND INFORMATION:

FOTO

1. LAST NAME

2. FIRST NAME

3. MIDDLE NAME

4. DATE OF BIRTH

5. PLACE OF BIRTH

6. NATIONALITY

7. HEIGHT

8. WEIGHT

9. COLOUR OF EYES

10. HOME ADDRESS:

CITY

COUNTRY

ADDRESS

11. TELEPHONE NO.

12. MOBILE

13. E-MAIL

14. MARITAL STATUS

PART II. NEXT OF KIN

15. NEXT OF KIN

LAST NAME

NAME

RELATIONSHIP

TELEPHONE

16. N.O.K. ADDRESS:

CITY

COUNTRY

ADDRESS

PART III. PASSPORTS

PASSPORTS

NUMBER

PLACE OF ISSUE

ISSUED ON

VALID TILL

National passport

National Seaman's Passport

International Travel Passport

PART IV. VISAS

VISA

ISSUED ON

VALID TILL

VISA

ISSUED ON

VALID TILL

USA

SCHENGEN

GERMAN (WORKING)

PART V. NATIONAL CERTIFICATES OF COMPETENCY

LICENSE

CAPACITY (REGULATION)

NUMBER

PLACE OF ISSUE

ISSUED ON

VALID TILL

Certificate of Competency

Certificate of Competency

PART VI. CERTIFICATES

PART VII. CERTIFICATES (DECK OFFICERS)

CERTIFICATE

ISSUED ON

VALID TILL

CERTIFICATE

ISSUED ON

VALID TILL

Med. Examination

GMDSS (R.O.C. / G.O.C.)

Yellow Fever

Endorsement of GMDSS

Basic Safety Training

ARPA

Proficiency in Survival Craft

Radar Observer

Advanced Fire Fighting

Medical Care

Medical First Aid

Ship Security Officer (S.S.O.)

HAZMAT

Bridge Team Management

HAZMAT (st. 49, USA)

ECDIS

Stability Courses

PART VIII. FLAG STATE DOCUMENTS

FLAG

DOCUMENT

GRADE

ISSUED ON

VALID TILL

FLAG

DOCUMENT

GRADE

ISSUED ON

VALID TILL

GERMANY

Seaman's Book

GIBRALTAR

Endorsement

Endorsement

MADEIRA

Endorsement

GMDSS

NETH. ANT.

Seaman's Book

A&B

Seaman's Book

Endorsement

Endorsement

LIBERIA

Seaman's Book

Endorsement

Endorsement

PART IX. NAUTICAL EDUCATION

ESTABLISHMENT (NAME OF COLLEGE/SCHOOL)

CITY

COUNTRY

DATES ATTENDED

DEGREE

FROM

TO

PART X. REMARKS

PART XI. DETAILS OF PREVIOUS SEA SERVICE

RANK

NAME OF VESSEL

FLAG

YEAR OF BUILT

TYPE OF VESSEL

GRT

TYPE OF ENGINE

POWER, kW

CARGO GEARS

SHIP OWNER / MANAGER

PERIOD OF SERVICE

TTL MM

FROM

TO

PART XII. REFERENCE VERIFICATION RESULTS

ORGANIZATION

NAME OF ORGANIZATION

COUNTRY / CITY

TELEPHONE

P.I.C.

EVALUATION

SUITABLE FOR REEMPLOYMENT (YES/NO)

REMARKS

ABILITY

SOBRIETY

DILIGENCE

1

SHIP OWNER / MANAGER

MANNING AGENT

2

SHIP OWNER / MANAGER

MANNING AGENT

3

SHIP OWNER / MANAGER

MANNING AGENT

PART XIII. INTERVIEW NOTES

INTERVIEW DATE

INTERVIEWED BY

LEVEL OF ENGLISH

APPEARANCE

EXPERIENCE WITH MULTINATIONAL CREW (LIST NATIONALITIES)

INTERVIEWER REMARKS

PART XIV. DECK DEPARTMENT

CONTAINERS, MAX. TEU

BULK (LIST CARGOS)

GENERAL CARGO (LIST CARGOS)

HEAVY-LIFT CARGO (LIST CARGOS)

PROJECT CARGO (LIST CARGOS)

TRADE AREAS

NOTES

PART XV. ENGINE DEPARTMENT

H.F.O., GRADE

4-STROKE ENGINES (LIST TYPES)

2-STROKE ENGINES (LIST TYPES)

PURIFIERS

WELDING SKILLS

TURNING SKILLS

CRANE/DERRICK TYPES

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