International Baltic Services Ltd
Tel: +7812325-3811 Fax: +7812325-3812
e-mail:
APPLICATION FORM
English: ( Bad / Fair / Good/ Excellent )
Position applied for: / Date Available for Joining:
PERSONAL DETAILS:
Surname: / Date of Birth:
First Name: / Place of Birth:
Middle Name: / Nationality:
Permanent Address:
Telephone No.: /  +7 / Fax. No.: /  +7
Telephone No.: /  +7 / E-mail:
Mobil Tel. No.: / +
DOCUMENTS:
Seaman’s Passport No. / Place of Issue:
Date of Issue: / Date of Expiry:
Travel Passport No. / Place of Issue:
Date of Issue: / Date of Expiry:
Seaman’ Book No. / Country
Date of Issue: / Date of Expiry:
Seaman’ Book No. / Country
Date of Issue: / Date of Expiry:
USA visa / Issued: / Valid till:
Other: / Issued: / Valid till:
FAMILY:
Marital Status: / Name of spouse:
Next of Kin: / Home Tel. No.:  / +7
Relationship: / Office Tel. No.: / +7
Address: / Same address
MEDICAL INFORMATION:
Medical examination: / Clinic: / Issued: / Valid till:
VACCINATIONS (valid for duration of contract). Date of vaccination:
Cholera: / Yellow Fever: / Tetanus: / Hepatitis B:
LICENCE PARTICULARS :
MOT / Grade / Cert No / Place of Issue / Date of Issue / Date Expires
National Licence
Tanker endorsement / Crude Oil
Liquid chemical
Liquefied gas
Panamanian endorsement:
Liberian endorsement:
Bahamian endorsement:
Other: / Cyprus endorsement
Belize endorsement
S. T. C. W. COURSES :
Radar observation and plotting simulator
Automatic Radar Plotting Aids
G.M.D.S.S.
Personnel Survival Techniques
Personal Safety and Social Responsibilities
Fire prevention and Fire-fighting
Elementary First Aid
Medical First Aid (Table A-VI/4-1)
Advanced Medical Care (Table A-VI/1, A-VI/4)
Advanced Fire fighting
Proficiency in survival craft, rescue boats
Fast Rescue Boat Leader
Oil tanker familiarization course
The specialized oil-tanker training programme including: Crude oil washing operations / Inert gas system)
Chemical tanker familiarization course
The specialized chemical tanker training programme
Carriage of dangerous and hazardous substances
Hazardous material training program (Subchapter “C”, Title 49, Code of Federal Regulation (USA)
Liquefied gas tanker certificate
Prevention and Fighting Marine Pollution
Manoeuvring & Ship handling (Section AII/I)
ROP/ARPA
Ship Security Officer
Professional Qualifications:
ESTABLISHMENT Name (Nautical College / Institute) / Date Attended

DETAILS OF PREVIOUS SEA SERVICE (last 7-10 years)

Name of Vessel / Flag / Type of Vessel / DWT / Type of Engine / B.H.P / Name of Ship Owner or Manager / Rank / Period of Service
Eyes: / Hair: / Height: / Weight: / Shoes: / Overall:

SHIP OWNER’S DATA (FOR REFERENCES)

COMPANY / TEL/FAX / CONTACT PERSON

CREW AGENCIES DATA (FOR REFERENCES)

VESSEL / CREW AGENCY / TEL/FAX / CONTACT PERSON

ABBRAVIATIONS:

Flags:

RUS / Russia / SING / Singapore / DIS / Denmark (2nd Register) / CAMB / Cambodia
PAN / Panama / HONG / Hong Kong / DNK / Denmark / GR / Greece
ANTG / Antigua & Barbuda / MI / Marshall Islands / NIS / Norway (2nd Register) / NA / Netherland Antillas
MALT / Malta / AUS / Austria / IOM / Isle Of Man / UA / United Arab Emirates
DEU / Germany / UKR / Ukraine / LUX / Luxemburg / IRA / Iran
FIN / Finland / PAK / Pakistan / LVA / Latvia / SV / St.Vincent & Grenadines
SWED / Sweden / THAI / Thailand / LTU / Litva / ALB / Albania
POL / Poland / IRL / Ireland / NOR / Norway / ALG / Algeria
VA / Vanuatu / TAIW / Taiwan / BMU / Bermudas / ANG / Angola
CYP / Cyprus / TURK / Turkey / EST / Estonia / ARU / Aruba
GBR / Great Britain / FRA / France / LBR / Liberia / AUSL / Australia
NLD / Holland / S.AR / Saudi Arabia / HUNG / Hungary / MN / Monaco
BHS / Bahamas / BLZ / Belize / HAIT / Haiti / BULG / Bulgaria
HOND / Honduras / BRB / Barbados / VENZ / Venezuela / TUVL / Tuvalu
ITA / Italy / ROM / Romania / VIET / Vietnam / NIG / Nigeria

Vessels:

DRY/C / Сухогруз / SUPPL / Снабженец / RO-FLW / RO-FLOW
CN / Контейнеровоз / LPG/C / Газовоз / SCIENT / Научно-исследовательское
RO-RO / RO-RO / ICE/B / Ice-Breaker / LO-RO / LO-RO
GEN/C / Генеральные грузы / TROWLER / Траулер / LC / Livestock Carrier
TIMB/C / Timber Carrier / TALL / Парусник / FERRY / Паром
BULK / Bulker / OFFSHORE / Нефте-вышки / FISH.Fact / Рыбообрабатывающая фабрик
TUG / Буксир / MULT / Многоцелевое
TANK / Танкер / CRANE / Плавкран
PASSG / Пассажирское / CT / Chemical Tanker
REEF / Рефрижератор / DRGR / Dredger Землечерпалка