TIDEMARINE LTD.

12/2, Ave. Shevchenko, office 3, P.O. 65058, Odessa, Ukraine

Telephone: +380-48-7065516 / +380-68-7458413 / +380-93-4618307 / +380-95-2516243

Email: , Website:

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OFFSHORE STAFF APPLICATION FORM

PERSONAL INFORMATION

Position Applied / Vessel Type
Lowest Position Acceptable / Place of Birth
Name / Date of Birth
Availability Date / Nearest Airport
Current Address / Age
Religion / Weight (kg)
Marital status / Height (cm)
Nationality / Email Address
Home Tel / Eye color
Cell phone - 1 / Cell phone - 2
Blood group / Hair color
Coverall size / Shoe size

PREVIOUS EMPLOYER REFERENCES (AT LEAST TWO LAST MUST BE STATED)

Employer Name / Post Address / E-mail ID / Person in charge (name & occupation) / Phone number / Fax number
Tidewater Marine, Luanda
Whitesea Shipping and Supply

CHARTER APPROVAL STATUS

Charter Name / Approval Date / Approval ID number
ARAMCO
PETROBRAS
PETRONAS
SHELL
TOTAL

PASSPORTS & VISA INFORMATION

National Passport No / Date of Issue / Date of Expire
Civil ID number / Date of Issue / NA
International Passport No / Date of Issue / Date of Expire
Seaman Book No / Date of Issue / Date of Expire
USA visa number / type / Date of Issue / Date of Expire
UAE Visa / type / Date of Issue / Date of Expire
Saudi Visa / type / Date of Issue / Date of Expire
EU Shengen Visa / type / Date of Issue / Date of Expire

CERTIFICATE OF COMPETENCY

Competency Certificate Grade & Number / Date of Issue
Date of Expiry
Issuing Authority
Certificate Limitation / Type
Authentication of COC number / Date of Issue
Endorsement Certificate / No. / Date of Issue
Date of Expiry
Issuing Authority
GMDSS license grade and number / Date of Issue
Date of Expiry
Issuing Authority
Endorsement GMDSS / No. / Date of Expiry
Issuing Authority
Authentication of COC number / Date of Issue
Flag state License grade & number
Certificate of Recognition / Date of Expiry
Issuing Authority
Limitation

STCW CERTIFICATES

Certificates / Institution / Place Issued / Number / Grade / Date of Issue / Date of Expiry
Advanced Fire fighting
Basic Fire fighting
Medical First Aid
Personal Safety and Social Responsibility
Proficiency in Survival Craft and Rescue Boat
Basic Safety Training (BST)
Medical Care
Proficiency in Survival Craft & Fast Rescue Craft
Fast Rescue Craft
Auto Radar and Plotting aids (ARPA)
Radar Observer
Radar Simulator
Ship Simulator and Bridge management
GMDSS (GOC) Course
Bridge Resource Management
ECDIS
IMDG course ( HASMAT)
Ship Safety Officer
Ship Security Officer
Designated Shipboard Security Duties
Shipboard Security Awareness
Food Handling Certificate
Crew Resource Management
BOSIET
HUET
FOET
SCBA awareness certificate
Offshore Safety Familiarization
Offshore Medical Certificate
Ship Master planned maintenance system
NEBOSH International General Certificate
IOSH (occupational health & safety)
Personal Survival Technique
Helicopter Landing Officer (HLO)
H2S ( Hydrogen Sulfide )
Risk management & Assessment
Tanker Familiarization / Endorsement (DCE)
Other
DP Certification (Please tick accordingly)
Type of Certificate / Basic / Advanced
Limited / Full
DP Certificate type and approval / Certificate number / Date of issue / Date of expire
Full DP Ticket
DPOCertificate limited
DP Advanced
DP Basic
DP Maintenance (only for Engineers)
DP HV Maintenance (only for Engineers) /
Duration of DP Watch Keeping
Vessel Class

DP CERTIFICATION SECTION

MEDICAL EXAMINATION INFORMATION
Last medical examination report number and type:
Date of Issue / Date of Expiry
Remarks on health condition
Vaccinations
Yellow Fever / Date of Issue / Date of Expiry
Cholera / Date of Issue / Date of Expiry
Others / Date of Issue / Date of Expiry

EDUCATION & PRE-SEA TRAINING DETAILS

From / To / Schools/Institutions/Universities attended / Qualifications Obtained / Degree

QUALIFICATION/ENGLISH TEST RESULTS

UK ON-LINE MARLINS TEST(please state score in empty cells)

Listening / Grammar / Vocabulary / Time & Numbers / Pronunciation / Reading

UK CEC

Total score of UK On-line UK CEC to be stated

ASHORE WORK EXPERIENCE (if any)

From / To / Employer / Rank / Work scope / Employer details (e.g. address, contact information)

Form: CREW-001-Offshore Staff Created by OS

Application Approved by OY& VM

Page 1 of 14

TIDEMARINE LTD.

12/2, Ave. Shevchenko, office 3, P.O. 65058, Odessa, Ukraine

Telephone: +380-48-7065516 / +380-68-7458413 / +380-93-4618307 / +380-95-2516243

Email: , Website:

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RECORD OF SEA SERVICE

No / Ship’s Name / Vessel Type / DP class / Main Engine manuf / model / GRT / DWT / Propulsion type / HP / Rank / Shipowner / Management Name / Client / Charterer Name / Work scope / DP hours (if any) / Trading Area / Oilfield names / Sign On Date / Sign Off Date / Sea Time
Year / Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

RIG MOVE EXPERIENCE DETAILS FOR AHTSS MASTERS ONLY

Nos. / VESSEL NAME / IMO Number / RIG NAME / DATE OF MOVE / WORK LOCATION / LEAD BOAT?
YES / NO

ANCHOR HANDLING OPERATION EXPERIENCE FOR MASTERS ONLY

VESSEL NAME / DURATION / OWNER / CHARTERER / AREA OF OPEARATION /OILFIELD / NAME OF BARGE ASSOCIATED WITH ANCHOR HANDLING OPERATION / NATURE OF ANCHOR HANDLING OPERATIONS, I.E.PIPELAYING, WELL MAINTENANCE SERVICE, RIG MOVE, BARGE TOWING AND ETC. / TYPE AND WEIGHT OF ANCHORS HANDLED
DATE FROM / DATE TO

Form: CREW-001-Offshore Staff Created by OS

Application Approved by OY& VM

Page 1 of 14

TIDEMARINE LTD.

12/2, Ave. Shevchenko, office 3, P.O. 65058, Odessa, Ukraine

Telephone: +380-48-7065516 / +380-68-7458413 / +380-93-4618307 / +380-95-2516243

Email: , Website:

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EXPERIENCE:

A)Total actual Sea Time to Date / Year / Month / Day
B) Total actual Sea Time in different type of vessels:
Actual Sea Time to Date: / Vessel Type / Year / Month / Day
AHT
AHTS
PSV
DSV
ROV
Construction
Accommodation/Work Barge
Crew Boat
Jack up barge
Others (LPG / OIL / Chemical)
Actual Sea Time on Azimuth Propelled Vessels
Actual Number of: / Rig Moves
Tows
Actual Ship Handling Hours of off shore vessels
Maximum Water Depth During Anchor Handling Operations (if any)
C) Deck Officers / DPO / Engineers / ETO Applicant for DP vessel:
DP Time in Various DP System
DP System / Model of DP system / No. of Hours
(DPO) / Length of Service (Days)
(Engineer / ETO)
Kongsberg
Alstom
Nautronix
Converteam
Bridge Mate
Imtech, Beier
Others (State)
DP Time in Various DP Reference System
DP Reference System / No. of Hours / Remarks
Hydro-Acoustic Positioning Systems, HiPap, etc…
FanBeam & Cyscan
Radius & RadaScan
DARPS, Differential, Absolute and Relative Positioning System
Taut Wire
Artemis
Others (State)
DP Time in Various Operations
Operation / No. of Hours / Other Operation (please state) / No. of Hours
AHTS
PSV
ROV
Dive Support
Cable Laying
Pipe Laying

NEXT OF KIN (Emergency Contact person)

Name / Relationship
Residential Address / Email Address
Home Telephone / Contact No.
Family Particulars (Please include Parents, Spouse, Siblings and Children)
Name / Relationship / Age / Date of Birth / Residential Address/Contact numbers
Father
Mother
Wife
Children (M/F)
Children (M/F)
Children (M/F)

BLANK PAGES:

  1. No of Blank pages left in Passport:

  1. No of Blank Pages Left in Seaman book

BANK DETAILS INFORMATION:

Name of bank
Beneficiary Name
Bank Address
Bank Swift
Account Number
Correspondent Bank Name
Correspondent Bank Account Number
Correspondent Bank Swift Number
Correspondent Bank Address

SELF DECLARATION

Answer Yes or No to the following questions. If Yes, give details below / Yes / No
1 / Has any previous employer dismissed you for misconduct?
2 / Have you had any serious illness, injury or operation affection your work
3 / Do you have any physical handicap including eyesight or hearing
4 / Have you ever being convicted in a court of law in any country
I hereby certify that the above information provided by me is true and complete.
______
Signature Date

Form: CREW-001-Offshore Staff Created by OS

Application Approved by OY& VM

Page 1 of 14