Document 001
Revision 1
Jan 2015
Quality Management System
PARALLAX MARINE APPLICATION FORM
Page 1 of 3
EMPLOYMENT APPLICATION FORM
Position applied for:
Availability date:
Date of this application:
Surname:
First name and other names:
Nationality:
photo
Date of birth:
Place of birth:
Marital status:
Height (cm):
Gender:
Weight (kg)
Shoe size:
Address:
Phones:
Nearest international airport:
Nearest domestic airport:
Next Of Kin: Surname, Name
Relation:
Address:
Coverall size:
e-mail:
Phone:
e-mail:
Children surnames, names and dates of birth:
School / College / University
1.
2.
3.
4.
EDUCATION
From
To
Obtained Certificate / Diploma
MEDICAL HISTORY – answer with YES or NO as applicable.
Have you ever been disembarked from ship for medical reasons?
Have you been hospitalized or consulted a doctor in the past 12 months?
Do you have any medical problem, disease or illness such us diabetes, high blood pressure, hernia
or other?
Have you ever tested positive on drug and alcohol test?
If you replied any questions with YES then please provide more details below (add extra page if necessary):
1.
2.
3.
SERVICE HISTORY – answer with YES or NO as applicable.
Have you ever been involved in maritime accident involving loss of live?
Have you ever been involved in maritime accident involving damage or loss of property?
Have you ever been involved in maritime incident involving oil pollution to environment?
If you replied any questions with YES then please provide more details below (add extra page if necessary):
GENERAL QUESTIONS
What wages do you expect per month?
What contract duration you require?
May you consider to join in lower rank?
Why did you leave your last employer?
Type of Ship you apply for?
Parallax Marine Ltd. No. 67. 1st Floor, Demokrazia Boulevard., 8000 Burgas, Bulgaria / +359 56 70 22 88 (Direct) / +359 882 71 65 02 (Direct) /
+359 887 05 79 88 (Mob. Phone) E-Mail: office@parallaxmarine.com
Document 001
Revision 1
Jan 2015
Page 2 of 3
Quality Management System
PARALLAX MARINE APPLICATION FORM
SEA SERVICE
Rank
Company
Vessel name
Type
– last contract on top
DWT
ME make
ME power
From
To
Reason to sign off
CONSOLIDATED SEA SERVICE
Ship Type
Rank
Service in months
ME Type
For Engineers only
Container Ship
Bulk Carrier
MPP / MPC
Tanker / Chem. Tanker
VLCC / ULCC
LPG / LNG
Passenger Ship
Other
Rank
Service in months
Sulzer
B&W
MAN
Pielstick
Gas Turbine
Steam Turbine
Other
REFERENCES
Company
Contact Person and Position
Do you agree that we contact your previous employers for references? Please write YES or NO as applicable:
Parallax Marine Ltd. No. 67. 1st Floor, Demokrazia Boulevard., 8000 Burgas, Bulgaria / +359 56 70 22 88 (Direct) / +359 882 71 65 02 (Direct) /
+359 887 05 79 88 (Mob. Phone) E-Mail: office@parallaxmarine.com
Contact numbers and e-mail
Document 001
Revision 1
Jan 2015
Quality Management System
APPLICATION FORM
Page 3 of 3
TRAVEL DOCUMENTS (national)
Document
Number
Date of issue
Valid till
Place of issue
Remarks
Passport
Seaman’s book
Seaman’s Pass.
US visa C1/D
CERTIFICATES OF COMPETENCY AND PROFECIONAL QUALIFICATIONS
Certificate
Number
Date of issue
Valid till
Place of issue
Remarks
Certificate of competency
GMDSS
ECDIS generic training
Marine Environment Awareness
Bridge Team Management
Advanced Fire Fighting
Medical Care
Medical First aid
Proficiency in Survival Craft and
Rescue Boats
Basic Safety Training (all 4)
Ship’s Security Officer
Designated Security Duties
Security Awareness
HAZMAT
Tanker Familiarization (Oil / Gas /
Chemical)
Tanker Operation (Oil / Gas /
Chemical)
Crude Oil Washing
Inert Gas Systems
Ship handling & maneuvering
ARPA & Radar observer
MEDICAL CERTIFICATES AND VACCINATIONS
Certificate
Number
Date of issue
Valid till
Place of issue
Remarks
Medical Certificate
Yellow Fever Vaccination
FLAG STATE DOCUMENTS - please list any valid flag state Endorsements and SBKs that you have
Document
Number
Date of issue
Valid till
Place of issue
Remarks
I certify that the information in this application is true and correct. I fully understand and agree that any
false declaration made by me herein shall result in instant dismissal without any responsibility or liability
whatsoever on the part of the company.
Hereby I declare my written personal consent to Parallax Marine Ltd. for gathering and processing my personal data, which I have submitted by voluntarily applying with this
application form. I wish and instruct Parallax Marine Ltd to search for a job suitable for me and according my qualification, to act as an agent between myself and employers, to
keep me informed of vacant posts, to pass my profile data to employers, to handle my personal data in accordance with Bulgarian legislation (чл.4, ал.1 т.2, чл.5, ал. 2 т.2 и
чл.36а, ал.6 от ЗЗЛД).
_________________________
date
________________________
Signature of Applicant
Parallax Marine Ltd. No. 67. 1st Floor, Demokrazia Boulevard., 8000 Burgas, Bulgaria / +359 56 70 22 88 (Direct) / +359 882 71 65 02 (Direct) /
+359 887 05 79 88 (Mob. Phone) E-Mail: office@parallaxmarine.com