APPLICATION FORM FOR EMPLOYMENT – Direct Hire - TANKERS CR10

Position applied for: / Address/Telephone No:
Availability:
Surname:
Forename: / Nearest Airport:
Date of Birth: / Marital Status: / No. of Children:
Place of Birth: / Next of Kin:
Nationality: / Address:
Religion:
FOR OFFICE USE ONLY
Height: / Languages: / English Assessment Grade:
Weight:
Documents / Grade / Number / Date Issue / Place Issued / Valid Until
National Licence
Endorsement
Flag St. Lic.
Flag St. Cert.
e.g. GMDSS-GOC
Flag St. S/Book
USA Visa / Type:
Vaccination valid until / Passport:
Yellow fever / S/B Nat:
Cholera / S/B Pass.

PREVIOUS EXPERIENCE (FOR LAST FIVE YEARS):

From / To / Vsl’s name / Flag / DWT / KW / Engine Brand/Type
4/2 stroke / Type of vsl / Ice Experience / Chemical Tanker / Position / Company / Manager’s Name

OTHER CERTIFICATES (Please tick the respective box)

Survival craft. / GMDSS / Advanced Medical / Tanker Safety 2
Survival techniques / GOC / Advanced fire fighting / COW
Basic fire fighting / ARPA / Fast rescue boat / IGS
Basic First Aid / Radar Obs. / Tanker safety 1 / Hazmat/ IMDG

I certify that the information contained in this application is true and complete. I understand that any false information, statement, omission or misrepresentation on this application form constitutes sufficient cause to refuse my employment or to dismiss me at a later stage, if employed withInterorient, irrespective of the timing the firm discovers the true facts.

I also express my consent to the processing of my personal data by Interorient, according to the provisions of the Personal Data Processing Law of 2001, for the purpose of evaluating my employment application. I understand thatInterorient will keep my personal data confidential.

The information you provide on this application formwill be used to the extent necessary within the company and its Branch offices and may be made available to shipowner clients for evaluation purposes.Wedo not sell, trade, exchange or otherwise make available your data to any other third parties with the exception of limited data within investigation reports as may be required by proper authorities.An individual may review the information we hold about him/her on their request. Any inaccuracies found will be promptly corrected.Apart from the aforementioned if we intend to transfer your information to any party outside of the European Economic Area we will always obtain your consent first. We place high value on your privacy and your dataand we are committed to the protection and security of your data.

Name: …………………………………………

Signature: ……………………………………

Date: …………………………………………

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Revised February 2008