APPLICATION FOR EMPLOYMENT

1.  Personal Data

Surname
/ Name / Father's Name
/ Permanent address: Georgia, Adjara, Batumi
Citizenship
Georgian / Date of birth
/ Place of birth
Georgia / É+995422 2
È+995
Document / No. / Date of issue / Place of issue / Valid until
Passport (Traveling) / Georgia

Seaman’s Book

/ Georgia
Liberian S. B.
Marshall Island S.B.
Cyprus S.B.
Panamanian S. B.

2.  Marine Education

Full Name of School / From / Till

3.  Certificates/Courses

Highest Competency certificate held:

Issuing authority / Grade/ STCW’95 Capacity / Certificate No. / Date/Place issued / Valid until
National Certificate of Comp / /Georgia
STCW 78/95 Endorsement / /Georgia
Liberian
Panamanian
Maltese

Last results of tests

Tests / Points / Date / Place
CES 4.1
Marlins

Dangerous cargo certification

Courses / Training center / Number / Date/ Place issued / Valid until
Crude Oil Washing / /Georgia
Inert Gas Systems / /Georgia
Hazardous Cargoes B-V/4;5
Tanker Special. (Oil) V/1-2 / /Georgia
Tanker Special.(Chem)V/1-2 / /Georgia
Tanker Special.(L Gas)V/1-2
Tanker familiar. (Oil) V/1
Tanker familiar. (Chem)V/1
Tanker familiar. (Gas) V/1

Other Certificates held and courses attended (include Liberian Special Qualification)

Courses/Certificate / Certificate N / Date/ Place issued / Valid until
Basic safety training and instruct. /
VI/I
/ / Georgia

Proficiency in Survival Craft

/

VI/2

/ / Georgia
Fire Fighting advanced / VI/3 / / Georgia
Medical first aid / VI/4-1 / / Georgia
Medical care / VI/4-2
Radar Observer Radar Simulator / / Georgia
ARPA / / Georgia
Marpol
GMDSS GENERAL / IV/2 / / Georgia
GMDSS ENDORSEMENT
Bridge Team mgmt
Ship’s Handling Certificate
ECDIS / VI/4-1
Engine room management
Ship security officer (ISPS code) / / Georgia
Ship safety officer IMOA741(18)
ISM code / / Georgia
Yellow Fever Vaccination Certif. / / Georgia

4.  Visas

Country / Visa Type/Class / No. / Date Issued / Place Issued / Valid Until
USA / C1/D

5.  Sea Experience: (Last 5 years - Most recent experience on top line)

Company / Vessel/
IMO / Flag / Vessel
Type / DWT / HP / Engine
type / Rank / Date from / Date
to

6. Last Employer Contacts

Name of Company / Tel: / Address: / P.I.C

7. General

(A) Nearest airport / Batumi/ Tbilisi/Trabzon

(B) Knowledge of language (good, fair, satisfactory, standard marine) Last salary: $

English / Russian / Other(Turkish)
1-V.Good/ 2-Good/ 3-Sat/ 4-St.marine

8. personel details & uniform information

Shoes size: / Overall: / Weight kg: / Height, cm: / Hair: BROWN / Eyes: HAZEL

Any additional useful info

1. Marital status: / 3. Mother’s name D.O.B / 4. Father’s name D.O.B
2.Children Under 18:
Name/ Surname / D.O.B
Wife
Children
Date/ signature Date availability for service

CD-P03

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