I Hereby Delare Having Duly Noted the Following
PLEASE ATTACH PHOTOGRAPH HERE
DATE OF AVAILABILITY:
1. PERSONAL INFORMATIONS
APPLIED RANK / OTHER ACCEPTED RANKS
LAST NAME / FIRST NAME
OTHER NAMES / NATIONALITY
DATE OF BIRTH / BIRTH PLACE
SEX / M☐ F ☐ / MARITAL STATUS
COLOUR OF EYES / COLOUR OF HAIR
FATHER’S NAME / MOTHER’S NAME
HEIGHT (CM) / WEIGHT (KG)
SHOE SIZE / BOILERSUIT SIZE (S,M,L,XL,XXL)
INTERNATIONAL AIRPORT (NEAREST TO HOME TOWN)
2. ADDRESS (PERMANENT)
STREET
POST CODE / PHONE
CITY / MOBILE
COUNTRY / E-MAIL
ADDRESS (TEMPORARY)
STREET / POST CODE
CITY / COUNTRY
3. NEXT OF KIN
FULL NAME
RELATIONSHIP / MOBILE/E-MAIL
STREET / POST CODE
CITY / COUNTRY
4. DETAILS OF CHILDREN (UNDER 18)
NAME OF CHILD / SEX / PLACE AND DATE OF BIRTH
M☐ F ☐
M☐ F ☐
M☐ F ☐
5. EDUCATION & LANGUAGES
NAME OF SCHOOL/ACADEMY
CITY / FROM: / TO:
ENGLISH / EXCELLENT ☐ GOOD ☐ AVERAGE ☐ POOR ☐
GERMAN / EXCELLENT ☐ GOOD ☐ AVERAGE ☐ POOR ☐
OTHER / EXCELLENT ☐ GOOD ☐ AVERAGE ☐ POOR ☐
6. LICENCES
TYPE OF DOCUMENT / NUMBER / ISSUE DATE / EXPIRY DATE / PLACE OF ISSUE
CERTIFICATE OF COMPETENCY
PASSPORT
VISA C1/D
SEAMAN'S BOOK
SEAMAN'S BOOK CYPRUS
SEAMAN'S BOOK LIBERIA
HEALTH CERTIFICATE MLC
YELLOW FEVER
POLIO
7. TRAININGS
TYPE OF DOCUMENT / NUMBER / ISSUE DATE / EXPIRY DATE
BASIC SAFETY TRAINING (4 IN 1)
BASIC FIRE FIGHTING
ELEMENTARY FIRST AID
PERSONAL SEAFETY AND SOCIAL RESPONSIBILITIES
PERSONAL SURVIVAL TECHNIQUES
PROF. IN SECURITY AWARENESS
PROF. FOR SEAFARERS WITH DESIGNATED SECURITY DUTIES
SHIP SECURITY OFFICER
MEDICAL FIRST AID
MEDICAL CARE
PROF. IN SURVIVAL CRAFT
FAST RESCUE BOATS
GMDSS
ARPA OPERATIONAL LEVEL
ARPA MANAGEMENT LEVEL
BRIDGE RESOURCE MANAGEMENT
ECDIS
ECDIS- SPECIFIED
HAZMAT
ENGINE ROOM RESOURCE MANAGEMENT
HIGH VOLTAGE
LIQUIFIED GAS TANKER FAMILIRISATION
OIL AND CHEMICAL TANKER FAMILIRISATION
ADVANCED GAS TANKER
ADVANCED OIL TANKER
ADVANCED CHEMICAL TANKER
CROWD MANAGEMENT
SAFETY TRAINING FOR PERSONNEL PROVIDING DIRECT SERVICE TO PASSENGERS
CRISIS MANAGEMENT AND HUMAN BEHAVIOUR
PASSENGER SAFETY, CARGOSAFETY AND HULL INTEGRITY
ADDITIONAL OFFSHORE CERTIFICATES
TYPE OF DOCUMENT / NUMBER / ISSUE DATE / EXPIRY DATE / PLACE OF ISSUE
BOSIET/FOET
HUET
HLO
DP BASIC
DP ADVANCED
DP UNLIMITED
CRANE OPERATOR
RIGGER
BANKSMAN/SLINGER
OTHERS
8. BANK ACCOUNT INFORMATIONS
ACCOUNT NO
SWIFT/BIC CODE
OWNER'S FULL NAME
OWNER'S ADDRESS
Polaris Maritime Services Ltd., ul. Jana Matejki 22, 70-530 Szczecin, Poland
phone: +48 91 4310 770; email:
/ Crew Application Form9. SEA SERVICE (LAST 5 YEARS)
COMPANY NAME / VESSEL NAME / RANK / SIGNED ON / SIGNED OFF / FLAG / VESSEL TYPE / ENGINE TYPE / KW / GRT
10. REFERENCES
COMPANY NAME
ADDRESS
PHONE NO.
FAX/E-MAIL
CONTACT PERSON
Name and Surname: / Date: / Signature:
I hereby authorise Polaris Maritime Services Ltd. To process my personal data included in this application for the pourpose of recruitment and placement process.
I hereby delare having duly noted the following:
1)Polaris Maritime Services Ltd is the administrator of the gathered personal data.
2)My personal data will be processed exclusively for the purposes of recruitment procedures, contract preparation, other documents required the course of my assignment on board, as well as preparation for departure.
3)My personal data may be disclosed to other entities exclusively for the purpose of support, realisation of recruitment and joining process, evaluation, control and monitoring, as well as reporting.
4)The submission of personal data is voluntary, the refusal to disclose it, however, will result in the lack of possibility of to gain support in the scope of the project.
5)I have the right to access and edit my personal data.
Polaris Maritime Services Ltd., ul. Jana Matejki 22, 70-530 Szczecin, Poland
phone: +48 91 4310 770; email: