Sea Going Experience for the Last 7 Years

/ MSC CREWING SERVICES
MSC House, 92-v Lustdorfskaya road, Odessa 65088, Ukraine
Tel.: +38 (0482) 333891
Fax.: +38 (048) 7055 200 / E-mail:
PERSONAL DATA / APPLICATION FORM
Position applied for ______License hold ______Date Available ______ /
Family Name: / Name: / Father's name:
Date of birth: / Place of birth: / Nationality: / Marital status:
Address: / Nearest Airport: / Home phone:
E-mail: / Mobile phone:
Next of kin and relationship: / Children (name & DOB):
Next of kin’s address: / Next of kin tel:
Inter. P’port No : / Date of issue: / Valid: / Place of issue:
Seaman's book No : / Date of issue: / Valid: / Place of issue:
Civil P’port No : / Date of issue: / Place of issue:
USA visa No : / Date of issue: / Valid: / Place of issue:
TOSE : / Date of issue: / MARLINS, %: / Date of issue:

SEA GOING EXPERIENCE FOR THE LAST 7 YEARS

(MOST RECENT VESSEL LAST)

Name of vessel / Year of built / Company Owner /
Ship Manager / Flag / Type of vessel / DWT / TEU / ME type / Model / BHP / Rank / From
DD/MM/YYYY / To
DD/MM/YYYY
Name of Maritime Institution attended / Address of institution / From / To / Degree of Diploma
STCW Certificates / Number / Issued / Valid / Place of issue / STCW Certificates / Number / Issued / Valid / Place of issue
Certificate of competency / BTM course
Endorsement / Personal safety
GMDSS Endorsement / Advanced fire fighting
Radar observer / Prof. in survival craft
ARPA / Survival / fast rescue boat
AIS course / Medical first aid
ECDIS course / Medical care
Security officer (ISPS) / Hazardous cargoes
Security Designated Duties / Training pers on pass.ships
Safety officer (ISM)
Medical examination / Issued: / Valid: / Weight, kg: / Height, cm:
Drug & alcohol test / Issued: / Valid: / Eyes: / Hair:
Yellow fever / Issued: / Valid: / Overall size: / Safety shoes:
Another States Seamen’s Books / Rank / Document No / Issued / Valid / Another States Certificates of competency / Rank / Document No / Issued / Valid
Liberia / Liberia
Panama / Panama

Please complete addresses of your previous employers for references

Company / Tel / Company / Tel
Address / Address

Мій підпис підтверджує мою остаточну та безсуперечну згоду на обробку (збір, накопичення, зберігання, прийняття, систематизацію, використання, розподіл, поновлювання, змінення, знищення, кодування та будь-які інші дії, необхідні для надавання посередницьких послуг з найму за кордоном і/або інших супровідних послуг) моїх особистих даних, що вказано в цій заявці з найму, а також будь-яких інших моїх особистих даних, що надаються до ТОВ «ЕМ ЕС СІ КРЮЇНГ СЕРВІСЕС»

Signature______Date ______I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.

Nationalities of crew sailed with:

CD-P03A1

Application Form Appendix 1 Second Issue Revision 0 Page 2 of 2