/ REEDEREI NORD GmbH
Astraturm – Zirkusweg 2
20359 Hamburg
Germany
Tel.: +49-40-3690-20
Mail:

SEAFARER APPLICATION FORM

RANK:

Manning agent:

PERSONAL DETAILS:

Surname: /

Name:

/ Availability date:
Date of Birth: / Place of Birth: / Other names: / Nationality:
Address: / Tel.No: / Mobile:
Nearest Airport:: / E-mail: / Civil Status:
Next of Kin/ Relationship: / Address: / Tel.No / Mobile:

TRAVEL DOCUMENTS:

Number / Issue date / Expiry date / Place
Passport:
National Seaman’s Book:
USA Visa:

LICENSES:

License / Grade of License / Number / Issue date / Expiry date / Place
Cert. of Competency:
Flag Certificates:

MEDICAL DOCUMENTS:

Number / Issue date / Expiry date / Place
Health Certificate:
Yellow Fever Vacc.:
Shoe Size (European standard) / Overal size (S/M/L/XL)
Height (cm) / Weight (KG)


COURSES & CERTIFICATES

Course name / Level / Issue date / Expiry date / Number
Fire Fighting / BASIC / ADV
Medical / ELEMENTARY First Aid /
MEDICAL FIRST AID
MEDICAL. CARE
Personal Safety & Social Resp.

Personal Survival Techniques

Survival Craft & Rescue Boats

Fast Rescue Boats
ARPA
GMDSS
Generic ECDIS
Type specific ECDIS 1
Type Specific ECDIS 2
Type specific ECDIS3
Ship Security Officer
Bridge Resource/ Team Mgmt.
Designated Security Duties

MARLINS / Language-lTest:

TOTAL % / LISTENING % / GRAMMAR % / VOCABULARY % / Issue date
TIME AND NUMBERS % / PRONUNCIATION % / READING % / Place of Issue
Last wages / Required wages

SEA SERVICE:

Ship-Owner / Rank / Date
signed on / Date
signed off / Type of vessel / Name of vessel / GRT / KW / If container
Nr. of TEU / Engine Type / Flag

Person or Company to contact for references, together with contact details.

1.

2.

3.

SIGNATURE / DATE and PLACE:

Wyrażam zgodę na przetwarzanie moich danych osobowych dla potrzeb niezbędnych do realizacji procesu rekrutacji (zgodnie z Ustawą z dnia 29.08.1997 roku o Ochronie Danych Osobowych; tekst jednolity: Dz. U. z 2002r. Nr 101, poz. 926 ze zm.).