ECM_003_2016


PHOTO

READY FROM: ______

SALARY: ______

APPLICATION FOR POSITION AS / OTHER POSITION (IF ANY)

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Figure 03, Revision 001, Dated 01.05.09

ECM_003_2016

1. PERSONAL DETAILS

TITLE MR/MRS/MISS / SEX / MALE / FEMALE
SURNAME
FIRST NAME / OTHERS NAMES
DATE OF BIRTH / PLACE OF BIRTH
NATIONALITY / MARITAL STATUS
COLOUR OF EYES / COLOUR OF HAIR
MOTHER’S NAME / FATHER’S NAME
MOTHER’S MAIDEN NAME
HEIGHT (CM) / WEIGHT (KG)
NEAREST INTERNATIONAL AIRPORT:
2. ADDRESS / ADDRESS (TEMP.) FROM/TO:
NO & STREET / NO & STREET
CITY / CITY
POST CODE / POST CODE
COUNTRY / COUNTRY
TEL. NO. / TEL. NO.
MOBILE / MOBILE
E-MAIL / E-MAIL
SKYPE NAME / FAX

3. NEXT OF KIN

FULL NAME / RELATIONSHIP
ADDRESS
CITY / COUNTRY
TEL. NO. / MOBILE / FAX NO.
4. CHILDREN
FULL NAME OF CHILD / DATE OF BIRTH / SEX
M / F
M / F
M / F
M / F

5. TRAVEL DOCUMENTS

TYPE / DOCUMENT NO. / ISS.DATE / EXP. DATE / ISS. BY (AUTHORITY) / PLACE OF ISSUE
TRAVEL PASSPORT
SEAMAN BOOK
OTHER SEAMAN BOOK
US C1/D VISA
OTHER VISAS

6. BANK ACCOUNT INFORMATION

BANK NAME / BRANCH
BANK ADDRESS
CITY / COUNTRY
SORT CODE / ACCOUNT NO
BANK SWIFT CODE / BANK TEL. NO
ACCOUNT OWNER’S NAME
ACCOUNT OWNER’S ADDRESS

7. EDUCATION

SCHOOL NAME / FROM / TO
SCHOOL NAME / FROM / TO

8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

CERTIFICATE NAME / NUMBER / ISSUE DATE / EXPIRY DATE / ISSUED BY (AUTHORITY) / ISSUED AT
DANGEROUS CARGO ENDORSEMENT / NUMBER / ISSUE DATE / EXPIRY DATE
PETROLEUM
CHEMICAL
GAS
9. LANGUAGES
ENGLISH / FLUENT / GOOD / FAIR / POOR
GERMAN / FLUENT / GOOD / FAIR / POOR
FRANCH / FLUENT / GOOD / FAIR / POOR
SPANISH / FLUENT / GOOD / FAIR / POOR
ITALIAN / FLUENT / GOOD / FAIR / POOR
RUSSIAN / FLUENT / GOOD / FAIR / POOR
MARLIN’S TEST / LEVEL / ISSUED DATE / RESULT % / ISSUED BY (AUTHORITY) / ISSUED AT
10. HEALTH CERTIFICATES & VACCINATIONS
FLAGE STATE / NUMBER / ISSUE DATE / EXPIRY DATE / ISSUED BY (AUTHORITY) / ISSUED AT
INTERNATIONAL
LIBERIAN
NORWEGIAN
PANAMANIAN
NAME / ISSUE DATE / EXPIRY DATE / ISSUED BY (AUTHORITY) / ISSUED AT
YELLOW FEVER
HEALTH LIST
DRUG TEST
11. SAFETY CLOTHING
BOILERSUIT SIZE / BOOTS SIZE
12. MARINE COURSES
COURSE NAME / NUMBER / ISSUE DATE / EXPIRY DATE / ISSUED BY (AUTHORITY) / ISSUED AT
BASIC SAFETY TRAINING AND INSTRUCTIONS
BASIC FIRE FIGHTING
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID
MEDICAL FIRST AID
MEDICAL CARE
PERS. SAFETY & SOC. RESP.
PROF. IN SURVIVAL CRAFT & RESCUE BOATS
FAST RESCUE CRAFT
G.M.D.S.S.
A.R.P.A. (Management level)
E.C.D.I.S.
RADAR OBSERVATION
HAZMAT
OIL TANKER
ADVANCE OIL TANKER
CHEMICAL TANKER
ADVANCE OIL TANKER
GAS TANKER
ADVANCE GAS TANKER
CRUDE OIL WASHING
INERT GAS PLANT
ISM CODE
SHIP SECURITY OFFICER
SHIP SAFETY OFFICER
BRIDGE TEAM MANAGEMENT
DP INDUCTION
DP SIMULATOR
BRIDGE / ENGIINE ROOM RESOURCE MANAGEMENT.
SHIP HANDLING
INTERNAL AUDITORS COURSE
TRAINING FOR SEAFARERS WITH DESIGNATED SECUIRITY DUTIES
SECUIRITY AWARENESS TRAINING FOR ALL SEAFARERS
ELECTICAL & ELECTRONIC EQUIPMENT
12. MARINE COURSES (CONTD……)
COURSE NAME / NUMBER / ISSUE DATE / EXPIRY DATE / ISSUED BY (AUTHORITY) / ISSUED AT
13. SPECIALISED EXPERIENCE
TYPE / FROM / TO / COMMENTS
NEW BUILDING
SPECIALISED PROJECTS
SPECIAL TRADES
SHORE EXPERIENCE

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Figure 03, Revision 001, Dated 01.05.09

ECM_003_2016

COMPLETE SEA – SERVICE DETAILS
( LAST VESSELS FIRST )
NAME: / RANK: / AVALIABILITY DATE:
COMPANY NAME / RANK / VESSEL NAME (FLAG) / SIGNED
ON / SIGNED OFF / PERIOD IN MONTHS
(eg 4.2) / TYPE OF VESSEL / D.W.T. / ENGINE TYPE
( ENGINEERS ONLY) / BHP / KW
REFERENCE CONTACT DETAILS
COMPANY NAME
ADDRESS
PHONE NO.
FAX/E-MAIL
CONTACT PERSON
I declare that the information I have given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are genuine, given and sign by persons whose names appear on them.
DATE / SIGNATURE

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Figure 03, Revision 001, Dated 01.05.09

ECM_003_2016

Officer Application Form / Ref .No
(For Official Use)
Medical History
Have you ever signed off from a ship due to medical reasons?
(If yes give details) / *yes/no
Name of Vessel / Date of occurrence (dd-mmm-yyyy)
Brief Description Of illness/Injury/Accident
Details
Have you ever suffered from any ailment or disease in the past that is likely to render you unfit for sea service or likely to endanger the health /well being of others onboard?
(If Yes give details) / *Yes/No
Details
Do you have any bodily defects or deficiencies?
(If Yes give details) / *Yes/No
Details
Are you currently suffering from any ailment or disease that is likely to render you unfit for sea service or likely to endanger the healthy /well being of others onboard?
(If Yes give details) / *Yes/No
Details
Are you addicted to alcohol or drug of any kind?
(If Yes give details) / *Yes/No
Details
Are you suffering from an ailment that requires you to be on a long -term treatment/medication?
(If Yes give details) / *Yes/No
Details
Have you ever deported or banned from entering any country?
(If Yes give details) / *Yes/No
Details
Have you ever been convicted of a criminal or drug offence or have any pending offences?
(If Yes give details) / *Yes/No
Details
Do you have any obligations towards your current/previous employers?
(If Yes give details) / *Yes/No
Having filled in this questionnaire in an electronic or paper look and having transferred it in any way to Euromarin Crew Management LTD, the questionnaire feeder thereby gives the consent, according to the Law of Ukraine "About protection of personal information" of 01.06.10 No. 2297-VI, on inclusion of the personal information in the Sailor database of Euromarin Crew Management LTD in the form of a card file and/or the automated information system, and also on their processing (collecting, registration, accumulation, termless storage, change, a depersonalization, destruction, updating, use, distribution, realization, transfer in full or partially to managers or the third parties) without additional written notice of it in the address, for the purpose of rendering by the company intermediary services in the employment in courts of foreign shipowners, irrespective of the country of theirlocation.
I am in writing notified on inclusion of my personal information in the Sailor database of Euromarin Crew Management LTD, on its location and the purposes of data collection, on persons to whom my personal information and about my rights in this regard will be transferred.
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief; further, that no certificate of competency or License issued to me has ever been Revoked or Suspended. I also certify that my medical history contained above is true and any false statement or undisclosed Material information about past illness or injury will disqualify me from any employment benefits and claims.
…………………………………….. ……………………………………..
dd-mmm-yyyy (Format) Signature

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Figure 03, Revision 001, Dated 01.05.09

ECM_003_2016

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Figure 03, Revision 001, Dated 01.05.09