1
Last name
*
:
First name
*
:
(as per Passport)
Citizenship:
2.
Date of birth
*
:
Nationality:
Place:
Country
*
:
3.
Passport No:
Issue Date:
Expiry Date:
Place of Issue:
4.
Permanent Address:
Phone
*
:
mob.Phone:
5.
Nearest Aiport/Station:
E-mail:
6.
Present Address:
Phone:
7.
Civil Status:
Please select
Single
Married
Separated
Divorced
Widowed
No. of Children:
8.
Next of kin:
Relation:
9.
Address of next of kin:
Phone:
10.
Wife and Children's
(up to 18) Name
Date of Birth
Passport No.
Date of Issue
Date of Expiry
Place of Issue
11.
Position Applied for:
Date of Availability:
Preferred contract length:
Expected Salary:
Preferred type of vessel:
Preferred sailing region:
12.
Seaman's Book
Number
Date of Issue
Date of Expiry
Country of Issue
Estonian
Russian
Latvian / Lithuanian
13.
Certificate of Competency
Number
Date of Issue
Date of Expiry
Country of Issue
STCW Endorsement
Number
Date of Issue
Date of Expiry
Country of Issue
14.
Courses/Certificates
Number
Date of Issue
Date of Expiry
Place of Issue
Personal Survival Techniques
Basic Fire Fighting
Elementary First Aid
Personal Safety and Social Responsibilities
Advanced Traning in Fire Fighting
Proficiency in Survival Craft and Rescue Boats
Medical Emergency-First Aid
Medical Care Onboard Ship
GMDSS General Operator Certificate
Radar Observer and Plotting Certificate
ARPA
Oil tanker familiarization / specialized training
Chemical tanker familiarization / specialized
Gas carrier familiarization/specialized training
Dangerous Goods at Sea
Bridge Team and Resource Management
Ship Handling and Maneuvering
ECDIS / Electronic charts
Maritime English
Revalidation course
SSO
ISM Code
Details of any courses/certificates not included in the above to specified in spare or unutilised columns.
15.
Schools Attend:
(including Pre-Sea Traning)
Name of School
Town / City
From
To
Type of degree/diploma received
16.
Languages:
Spoken
Written
Read
English
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
Please select
Fluent
Moderate
Weak
17.
Physical Declaration:
Height:
Weight:
Color of Hair:
Color of Eyes:
Medical Inspection
Date Issued:
Date of Expiry:
Country of Issue
Estonian
Other
Vacination
Date of Vacination
Date of Expiry:
Country of Issue
Yellow Fewer
Cholera
Other
18.
Previous Sea Services:
(Datewise upto 10 previous vessels ending with last. Expirience prior to that to be attached separately.)
Name of Vessel
Type of Vessel
Flag
DWT
Type of Engine
HP
Name of Owners or Managers
Rank
From (day, month, year)
To (day, month, year)
# Elec.Officer to mention UMS Experience, if any:
# Radio Officer to mention Radio Equipment make/Satcom/Telex:
20.
Boiler Suit size:
Please select
46
48
50
52
54
56
58
60
T-Shirt size:
Please select
S
M
L
XL
XXL
Working Shoes size:
Please select
38
39
40
41
42
43
44
45
46
47
21.
References (Please indicate at least one person who could give additional information about You)
No
Name of referee
Company
Post
Phone no
1.
2.