SEAFARER APPLICATION FORM

Personal Information

Rank *		Date of birth *
Surname *		Place of birth *
First name *		Citizenship *
Father’s name *		Passport #
Gender		Eyes color *
Height *	cm	Overall size *
Weight *	kg	Shoe size *
Hair color *
Marital status *

Photo *

Contact Information

Address *
City *
Country *
Email *
Home telephone
Mobile telephone *
Mobile telephone 2

Relatives

Full name

Relation

Date of birth

Actual address

Mobile telephone

Is next of kin

Sea service

At least 1 contract

Vessel name

Flag

Type

Engine

Crewing company

Rank

Sign on

Built

DWT

Power

Sign off

Education

At least 1 information

Institution

Faculty

Speciality

Start

Graduate

Work experience

Organisation

Name of job

Reason of dissmissal

Start

Graduate

Certificates

Documents title

Number

Issue date

Expiry date

Travel Passport *

Seaman's Book *

Certificate of Competency *

Certificate of Competency (II)

Basic STCW (A-VI/1) *

GMDSS

Proficiency in Survival Crafts

Fast Rescue Boats

Advanced Fire Fighting Course

Medical First Aid

RADAR/ARPA

Hazardous materials

Security Officer

Safety Officer

Risk assessment

ECDIS

Yellow Fever Vaccine

Security awareness training

Designated Security Duties

Foreign languages Information

Language

Level

Certificate

I, undersigned, confirm all above information to be true and correct to my best knowledge

	20.01.2020
	Date