GREEN SEA LTD
SHIPPING COMPANY GSL ODESSA
POSTAL ADDRESS:- ODESSA UKRAINE
Tel: +380959005525 , +380999243616,+37259251258.
Email : info_greensea@mail.ua.
Web site : WWW.GREENSEA-LTD.COM
Application Form
Deck & Engineering Officers
Section 1
Position
Position Applied for
Date of Availability
Section 2
Personal Details
Family name / Surname
First Name / Given Name
Date & Place of Birth
Nationality
Permanent Address
Present Address
PPE information
Present Contact Number
Mobile Number
SKYPE ADDRESS
Email Address
Nearest Airport (and Distance)
Section 3
SAFETY SHOES SIZE
USA Visa - Type
USA VISA Expires
USA Visa - Type
USA VISA Expires
Other Country Visa
Visa Expiry
Country of Issue
Date Issued
Place Issued
Passport Number
Passport –Expires
Secondary passport or Dual
nationality
Section 4 ( hi-light as required )
Issuing Country & Place
Number
Section 5
COVERALL SIZE
Seaman book / Discharge book / Seaman Record Book / CDC
Date Issued
Expiry Date (if any)
Next of Kin – this is important information we require- Don’t ignore it
Full Name / Relationship
Address
Contact Numbers
Signature :
WPIF – M/01
Page 1 of 7
12 TH July 2011
Rev - 02
Section 6
STCW95 Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)
Class /
Grade/Capacity
Issuing
Country
Certificate
No.
Date Issued
Expiry
Details of Limitations
Endorsement
ALSO ENTER ABOVE DETAILS OF ANY OTHER FLAG STATE CERTIFICATES HELD
Section 7
STCW95
Dangerous Cargo Endorsements
Certificate No.
Date Issued
Expires
Details of Limitations/ Grade
Petroleum…………….
Liquefied Gas……….
Liquid Chemicals…….
Section 8
STCW95 related Courses Attended and Certificates Obtained
Name of Course / Certificate
STCW Code
Place
Issue Date
Personal Survival Techniques
Basic Sea Survival / Training
Fire Prevention & Fire Fighting
Elementary First Aid
Personal Safety & Social
Responsibility
Proficiency in Survival Craft &
Rescue Boats
Proficiency in RESCUE CRAFTS
Advanced Fire Fighting
Medical & First Aid
Medical Care
( Ship Captains Medical Course )
Seafarers with designated security
duties
GMDSS + ENDORSEMENT
SAFETY OFFICERS COURSE (SO)
Ship Security Officers Course (SSO)
Issued under STCW95
Medical Certificate / HEALTH
Certificate
Drug and Alcohal test certificate
YELLOW FEVER
Bridge Team Management
Bridge Resources Management
Electronic chart Display and
Information System course ECDIS
ISM Code
PDSD CERTIFICATE
Advanced Tanker Operations
(Chem.)
Advanced Tanker Operations (Oil)
Advanced Tanker Operations (LPG)
INERT GAS
CRUDE OIL WASHING
Tanker Safety ( petroleum )
Tanker Safety ( Chemical )
Tanker Safety ( GAS )
REFRESHER & UPDATING
Expiry Date
A- VI/1-1
A-VI/1
A-VI/1-2
A-VI/1-3
A-VI/ 1-4
A-VI/ 2-1
A-6/2-2/
A-VI/ 3
A-VI/ 4-1
A-VI/4-2
A-6/6,Tab.
A-6/6-2
A-IV/ 2
A-VI/ 5
A-II/2
B-VIII/2
A.1441 (18)
A-V/1
A-V/1-2
A-V/1
A-V/1
I/II & III/2
SIGNATURE :
WPIF – M/01
Cert No
Page 2 of 7
12 TH July 2011
Rev - 02
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Section 9
OFFSHORE INDUSTRY COURSES
Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already
mentioned
Name of Course / Certificate
APPROVALS
Place
Issue Date
Cert No
Expiry
Agip KKO Personal HSE Passport
2. TB0SIET
FOET
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
Re-Breather training
Initial Standby vessel crews training (
ITSO )
CAA (Civil Aviation Authorities –
Helicopter)
Advanced Medical Aider ( AMA )
CES 4.1
MARLIN’s English Test
IELTS-English TEST
http://www.ielts.org/test_centre_search/search_results.aspx
SCORE
Listening %
Grammar %
Vocabulary % Time and
Pronunci
Number %
ation %
PMS maintenance system – Confirm that you are Familiar with its use ( YES / NO )
DEEP WATER ANCHOR HANDLING EXPERIENCE
ENTER DEPTTH IN METERS
DP Maintenance Courses
Makarov Training Centre
DP Maintenance Courses
HIGH VOLTAGE COURSE
Dynamic Positioning Induction Course
Dynamic Positioning Simulator Course
Dynamic Positioning Operators
CERTIFICATE
Dynamic Positioning Log book Details
Section 10
SYSTEM DETAILS
%
Reading
%
???????
Full or
Limited
Hours done with various DP system
Approx Hours as SDPO / Approx Days
in case of Senior ETO / Senior
Engineer
Approx Hours as DPO / Approx Days
in case of Junior ETO / Junior
Engineer
APPROXIMATE Total DP Hours in Various Operations
SAT DIVING
CABLE LAYING
AIR DIVING
SURVEY
ROV
PIPE LAYING
WELL STIMULATION /
DRILL SHIP / SEMI SUB
INTERVENTION / ACTIVATION
AHTS
PSV
FPSO
SHUTTLE TANKER
CONSTRUCTION
ROCK DUMPING /
MATTRESSING
CORING
TRENCHING
HEAVY LIFT
ACCOMMODATION / GANGWAY
WPIF – M/01
12 TH July 2011
Rev - 02
SIGNATURE :
Page 3 of 7
Section 11
Medical History
YES
Have you ever signed off a ship due medical reason ?
Have you undergone any medical operations in past ?
Have you consulted a doctor during the past 12 months for an illness /
Accident
Do you have any health or disability problem now ??
If answer to any of above is YES then give further details below or on a separate sheet
NO
NOTE : All our clients have STRICT Alcohol and Drug Policy, Which
means ZERO TOLERENCE for alcohol and drugs
Section 12
General
Yes
No
Have you ever been the subject of a court of enquiry or involved in a maritime
accident
Have you ever had a professional licence suspended or revoked
Have you ever been convicted of any criminal offence?
Have you ever been dismissed
If yes to any of above then please full details below or on separate sheet of paper
Section 13
References
(Last Two Recent Employers)
Name of company
Name Person to be contacted
Address
Tel No
Fax
Email
Name of company
Name Person to be contacted
Address
Tel No
Email
Section 14
Section 15
Fax
Any other information, you wish to add in support of your application
Declaration
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
And confirm that All my certificates / Licences are Authentic / SEASERVICE RECORD is ACCURATE / And I
confirm accepting Companies DRUG & ALCOHOL Policy
WPIF – M/01
12 TH July 2011
Rev - 02
Signed …
Page 4 of 7
WPIF – M/01
12 TH July 2011
Rev - 02
Section 16
VESSEL
Record of Sea Service
Please give full record of sea service
COMPANY
Type of Vessel
And Type of
operation in case of
DP vessels
DWT or
GRT
(please delete
as reqd)
Type of Engines :: for engineers only, DPOs to Mark DP System
(All Dates to be entered as dd/mm/yy)
STARTING FROM LAST VESSEL FIRST
Type of Engines
Or DP System
BHP
BHP : for Engineers and AHTS / TUG Masters & Officers
SIGNATURE:
WPIF – M/01
12 TH July 2011
Rev - 02
RANK
Sign on DATE
Page 5 + 6 of 7
Sign off DATE
ADDITIONAL INFORMATION SHEET
VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)
MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below)
Please Quote –Consolidated MINIMUM MONTHLY SALARY ( no leave pay ) payable for
time onboard only or Working DAY RATE EXPECTATION ( no leave pay)
(please quote below in US$ -preferred or Euro or GBP£ )
Languages Spoken / Written / Understood (1-poor
Spoken
Fluent
ENGLISH
5-Fluent)
Written
Fluent
Understood
Fluent
DRUG & ALCOHOL POLICY
ALL Our Clients have very strict NO DRUG and ALCOHOL POLICY, Which is required to be
complied with at all times, which means “””ZERO TOLERENCE on ALCOHOL & DRUG”””
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight
or commence your travel to join vessel, and Must remain so Until you have completed full
contract and returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL
EXPENCES incurred which will include all your travel and recruiting costs, And your relief’s
Travel and recruiting costs, And Any other costs whatsoever incurred due to your NONCOMPLIANCE will be deducted from your salary, Which will include but not limited to “damage to
vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly
connected with your NON-COMPLIANCE
Sign & CONFIRM ACCEPTANCE OF ABOVE POLICY………………………………………
FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US- send to us In separate Email
Licence or Certificate of competency, Any tanker endorsements, GMDSS showing expiry date in case of
Deck Officers, Medical Fitness / Examination Certificate, Passport Main page, Seaman book or
Discharge book Main pages, In case of DPO – DPO Cert, DP LOG Pages
FOLLOWING ADDITIONAL DOCUMENTS will ALSO BE REQUIRED – Send to us in separate email
All short courses certificates ( STCW95 ), SSO certificate, Last 3-5 years ships entries in Discharge book
or Seaman book, Certificate of Equivelant Competency from other flag states
PAGE 7 of 7
WPIF – M/01
12 TH July 2011
Rev - 02