Date of application: Click here to enter a date. Please upload picture here

Name of manning agent:

1. Personal Information

Rank / Alternative Rank (If Any)
Last Name / First Name
Other Names / Nationality
Sex / M☐ F☐ / Birth Place / Date of Birth

2. Maritime education:

Grade: / School: / Country: / Date (from – to):

3. Sea Service:

Vessel name / Vessel type / Flag / Rank / DWT / Maker, model, BHP/KW / From
(dd/mm/yyyy) / Until
(dd/mm/yyyy) / Y/M/D / Company
- /
- /
- /
- /
- /
- /
- /
- /
- /
- /
- /
- /
- /
- /
- /

7. Documents:

Document name: / Country: / Number: / Place of issue: / Date of issue: / Expiry date:
Passport:
Seaman’s book:
Others:

8. National license / endorsement:

Country: / Number: / Place of issue: / Date of issue: / Expiry date:
Highest rank on endorsement:
Valid for chemical tankers: / Choose an item. /
Valid for oil tankers: / Choose an item. /

9. Other Flag State licenses:

Country: / Number: / Place of issue: / Date of issue: / Expiry date:

10. Medical examination:

Country: / Date of issue: / Expiry date:

11. Drug & Alco:

Country: / Date of issue: / Expiry date:

12. Vaccination Yellow Fever:

Date of issue: / Expiry date:

13. Other Information:

Weight:
Height:
Marital Status: / Choose an item. /
Religion:
Color of Eyes
Color of Hair
Shirt Size
Trousers Size
Boiler suit Size (S,M,L,XL,XXL)
Shoes Size
Nearest international airport
Nearest domestic airport

4. Certificates:

Document Number: / Date of issue: / Expiry date:
Basic safety training, or:
Personal survival techniques
Fire prevention and fire fighting
Elementary First Aid
Personal Safety / Social Responsibility
Proficiency in survival craft / PSCRB
Advanced fire fighting
GMDSS
Medical care on board
Medical First aid
Radar navigator
Shiphandling (IMO model course 1.22)
Bridge team and resource management
Engine room resource management
Ship Security Officer
Designated Security Duties
ECDIS (generic – IMO model course 1.27, 40 hrs.)
ECDIS TOTEM type specific training
Tanker familiarization
Advanced chemical training
Advanced oil training
Ship Safety Officer
Ships Cook training certificate
Steward/Messman certificate
Incident Investigation
Chemical Simulator
Risk Assessment
Framo Pump Course

5. Visas:

Document Number: / Date of issue: / Expiry date:
US Visa (C1/D)
Schengen visa

6. Next of Kin:

Next of kin: / Relationship:
Telephone: / Date of birth:
Address:
Next of kin: / Relationship:
Telephone: / Date of birth:
Address:
Next of kin: / Relationship:
Telephone: / Date of birth:
Address:

8. Tanker Information Sheet - (For applications of Deck Officers, Bosun, Pumpman and deck ratings):

YES/NO / Year* / Rank** / Yes/No / Year* / Rank**
Chemical Products / Chemical Products
Aromatics: / Perchlorethylene / - / - /
Styrene / - / - / Trichlorethylene / - / - /
Toluene / - / - / MDI/TDI / - / - /
Benzene / - / - / Ethylene/Methylene Dichloride / - / - /
Xylene / - / - / Styrene Monomer / - / - /
Alcohols & Glykols / - / - / MethylTert-Butyl Ether (MTBE) / - / - /
Methanol / - / - / Butyl Acetate / - / - /
Ethanol / - / - / Acetone / - / - /
Iso-propyl Alcohol (IPA) / - / - / Acrylonitrile / - / - /
Butyl /Isobutyl Alcohol / - / - / Caustic Soda / - / - /
2-Ethylhexanol (Octanol) / - / - / Chloroform / - / - /
Mono Ethylene Glycol (MEG) / - / - / Phenols / - / - /
Molasses / - / - / Propylene Oxide / - / - /
Acids: / Vinyl Acetate Monomer (VAM) / - / - /
Phosphoric / - / - / Urea Ammonia Nitrate / - / - /
Sulphiric / - / - / Dowanol / - / - /
Acrylic / - / - /
Acetic / - / - / Clean Petroleum Products (CPP):
Paraffins: / Gasoil /Diesel Oil / - / - /
Slack Wax / - / - / ULSD / - / - /
Hexane / - / - / Gasoline / - / - /
Cyclohexane / - / - / Naphta / - / - /
Fuel Oil / - / - /
Vegoils***: / - / - / Luboils / - / - /

*Year: Enter year of latest experience || **Rank: enter highest rank of experience || *** Crude Palm Oil, Rapeseed Oil, Soybean Oil etc..

Parcel Trade Exp. (max. Nr. of parcels during single voyage):

Cargo Pumps Experience / Tank’s Coating Type Experience
Deepwell: / - / Expoxy / - /
Framo / - / Zinc Silicate / - /
Marflex (electrical driven) / - / Marineline / - /
Centrifugal / - / Stainless Steel / - /
Screw / - / Tank’s Passivation Experience / - /
Steam Turbine / - / Wall Wash Experience / - /
Vetting Inspections (indicate which)
CDI Inspection (indicate date of last inspection)
OCIMF Inspection (indicate date of last inspection)
USCG Inspection (indicate date of last inspection)
Dry Dock Experience (indicate shipyard)
Experience in Delivery of New Buildings
Trading Area (indicate areas)
Ice Navigation Experience (indicate areas)
Ship-to-Ship Experience (indicate areas)
Trondheim 20
2993 LE Barendrecht
The Netherlands / Tel. +31 180 55 52 70
Fax +31 180 55 52 79
E-mail / K.v.K 24384723
BTW/VAT Nr. 8150.01.691.B01