F-04 / 25.11.12
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SEAMAN INFORMATION LIST

Personal data

Full Name:
Address:
Home Phone No:
Mobile Phone No:
E mail:
Place of Birth:
Date of Birth:
Citizenship:
Expected Wage:
Nearest Airport:
Marital Status:
No of children supported:
Spoken Languages:
Education:
Height:
Weight:
Colour of Eyes: / Shoes:
Colour of Hair: / Identification Mark on Body:

Rank:

Next of Kin

Full Name: / Relationship:
Address: / Phone No:
Email: / Mobile No:

Passport

Country / Number / Place Issued / Date Issued / Expiry Date

Visa

Country / Number / Place Issued / Date Issued / Expiry Date

Certificate of Competency

Grade of License / Country / Number / Place Issued / Date Issued / Expiry Date

Seaman′s Book

Country / Number / Place Issued / Date Issued / Expiry Date

Medical

Medical Country / Place Issued / Date Issued / Expiry Date

Drug & Alcohol

Place Issued / Date Issued / Expiry Date

Yellow Fever

Place Issued / Date Issued / Expiry Date

Certification & Training

Certificate / Country / Number / Place Issued / Date Issued / Expiry Date
BASIC SOLAS
ADVANCED FIRE FIGHTING
PROFICIENCY IN SURV CRAFT
SHIP MEDICAL CARE
TANKER FAMILARIZATION
OIL TANKERS ADVANCED
CHEMICAL TANKERS ADVANCED
LIQUEFIED GAS TANKERS ADVANCED
RASSENGER SHIP FAMILARIZATION
PASSENGER SHIP TRAINING
PASSENGER SHIP CROWD MANAGEMENT
PASSENGER SHIP PASSENGER SAFETY
PASSENGER SHIP CRISIS MANAGEMENT
PERSONAL SURVIVAL TECHNIQUES
FIRE PREVENTION AND FIRE FIGHTING
ELEMENTARY FIRST AID
PERSONAL SAFETY AND SOC. RESPONSIBILITY
PROFICIENCY IN SURVIVAL CRAFT & RES. BOAT
PROFICIENCY IN MEDICAL FIRST AID
HAZMAT
COW CERTIFICATE
IGS CERTIFICATE
BRIDGE TEAM MANAGEMENT
SHIP SECURITY OFFICER
SHIP SAFETY OFFICER
GOC-GMDSS
ECDIS
ARPA
C.E.S. 4.1 TEST RESULT%
MARLIN'S TEST RESULT%
RADAR OBS & PLOT SIM.
EDUCATION (PRE SEA-TRAINING)
OTHER

Reference

Company Name
Name / Tel
e-mail
Reason for leaving last employer:
F-04 / 25.11.12
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Previous Sea Experience

Vessel Name / Vessel Type / Flag / Eng Type* / DWT / HP* / Company / Rank / Joined / Leave / Days on board

*for engineers only

Shore Based Experience

SITE / TYPE / TRADE / JOINED / LEAVE / MANNING AGENT

Physical Declaration:

VISION / Excellent / Good / Poor
With Glasses
Without Glasses
HEARING / Normal / Poor / Nil
Right Ear
Left Ear

Additional Information:

No / Yes / If Yes please give details
Are you involved in any marine accident/investigations? (Collision/Grounding/Fire/Pollution)
Did you suffer any accident which rendered you temporarily and / or partially disabled?
Are you currently under medical treatment or taking medication for existing conditions?
Did you suffer, or do you presently suffer from any diseases likely to render you unfit for sea service or likely to endager the health or other persons onboard?
Did you ever undergo psychiatric treatment?
Are you addicted to alcohol or drugs of any kind?
Cargo's carried:
Trading pattern:
Nationalities sailed with:
Cargo's gear's:
Computer skills:
Miscellaneous:

How did you come to know about us?

Company Presentation/Seminar / Told by seagoing friend(s)
Marine Club notice - board / Direct mail from Company
Marine magazine advertisement / Other (Please Specify)
Newspaper advertisement

Date of Availability:

Day / Month / Year

Remarks:

Declaration

I certify that the details given by me in filling up this application form are true, complete, and correct to best of my knowledge and belief.I also declare that the documents submitted are genuine and signed by the persons whose names appear on them.Our company and our provider keep the personal data and their contents in our database.We and the parties authorized by us never make your personal data available to third parties, unless you have consented.By completing this form, you are giving your explicit consent to the processing of the data in it, including anything that may be considered sensitive personal data.Personal data will be processed fairly and lawfully in adherence with the law and the universal declaration of human rights, Convention 108, Directive 95/46/EO, Directive 2002/58/EC.I the undersigned, agree to the use of my personal data included in the present application form as acquired by the requiting process.Reasonable and appropriate measures are taken to ensure that your personal data (including the information in your application) is protected from unauthorized access or modification, unlawful destruction and improper use.However, keep in mind, the internet is an open system and we can or do guarantee that the personal information you have submitted will not be intercepted by others.