AQUAMARINE SHIPPING PC
SEAFARER’S APPLICATION FORM
RANK:
PERSONAL DETAILS:
Surname:
Name:
Availability date:
Other names:
Nationality:
Address:
Tel.No:
Mobile:
Nearest Airport::
E-mail:
Civil Status:
Date of Birth:
Place of Birth:
Next of Kin/ Relationship:
Address:
Tel.No / Mobile:
TRAVEL DOCUMENTS:
Country
Number
Issue date
Expiry date
Place
Passport:
National Seaman’s Book:
USA Visa:
LICENSES:
License
Grade of License
Number
Issue date
Expiry date
Place
Cert. of
Competency:
Permission:
Flag Certificates:
MEDICAL DOCUMENTS:
Number
Health Certificate:
Drug & Alcohol Test:
Yellow Fever Vacc.:
Issue date
Expiry date
Place
AQUAMARINE SHIPPING PC
COURSES & CERTIFICATES
Course name
Level
Issue date
Fire Fighting
BASIC
Medical
ELEMENTARY First Aid
MEDICAL FIRST AID
MEDICAL. CARE
Expiry date
Number
/ ADV
/
Personal Safety & Social Resp.
Personal Survival Techniques
Survival Craft & Rescue Boats
Fast Rescue Boats
ARPA
GMDSS
Oil Tanker
BASIC
/ ADV
Chem Tanker
BASIC
/ ADV
LPG Tanker
BASIC
/ ADV
ECDIS
Ship Security Officer
Crowd Management
Crisis Management
Bridge Resource/ Team Mgmt.
Designated Duties
Security Awareness
MARLINS Test:
TOTAL %
LISTENING %
GRAMMAR %
TIME AND NUMBERS %
PRONUNCIATION %
READING %
VOCABULARY %
Issue date
Place of Issue
AQUAMARINE SHIPPING PC
SEA SERVICE:
Ship-Owner
Rank
Date
signed on
Date
signed off
Type of vessel
Name of vessel
GRT
KW
Engine Type
Flag
Person or Company to contact for references, together with contact details.
1.
2.
3.
CONTRACTUAL
I hereby affirm that all the information provided by me is true and correct to the best of my knowledge and belief. I further affirm that no
Certificate of Competency or License issued to me has ever been revoked or suspended and that they will remain valid during my anticipated
employment plus three months.
SIGNATURE
DATE and PLACE: