AZALEA MARITIME APPLICATION FORM / PM Section 2, Fr-17
Ver.5, Rev. date15/05/2018
Position applied for: / Choose rank / Ready from: / Click to enter date /
PERSONAL INFORMATION
Last name / /
First name
Date of birth
Place of birth
Nationality
Marital status / Select status /
Education history / Click to select /
Height (cm) / Weight (kg) / Blood type / Shoe size / Overall size / Army finished
Click to select / Click to select / / /
CONTACT INFORMATION
Address / Home phone
City / Mobile phone
Postal code / E-mail
Country / Nearest airport
NEXT OF KIN INFORMATION
Name / Relationship
Address / Home phone
City / Mobile phone
Postal code / E-mail
Country
TRAVEL DOCUMENTS (NATIONAL AND FLAG STATE) – valid only
Document type / Number / Country of issue / Place of issue / Date of issue / Date of expiry
Click to select / Click to enterdate / Clickto enterdate /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
CERTIFICATES OF COMPETENCE (NATIONAL AND FLAG STATE) – valid only
Certificate type / Number / Country of issue / Place of issue / Date of issue / Date of expiry
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
STCW CERTIFICATES (NATIONAL AND FLAG STATE) – valid only
Certificate type / Number / Country of issue / Place of issue / Date of issue / Date of expiry
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
MEDICAL CERTIFICATES AND VACCINATIONS – valid only
Document type / Number / Country of issue / Place of issue / Date of issue / Date of expiry
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
Click to select / Click to enter date / Click to enter date /
PREVIOUS EMPLOYER – for references
Company name / Country
Address / Contact person
City / Office phone
Postal code / E-mail

Please enter the sea service experience on the next page.

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AZALEA MARITIME APPLICATION FORM / PM Section 2, Fr-17
Ver.5, Rev. date15/05/2018
PREVIOUS SEA SERVICE EXPERIENCE – last 5 years or last 10 ships served
Vessel name / Flag / Type / GRT / Propulsion type / BHP / From / To / Rank / Manning Agent / Operator
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /
Click to select / Click to select / Click to enter date / Click to enter date / Choose rank /

In accordance with the provisions of the General Data Protection Regulation (EU) 2016/679, we inform you that the information you provide will be registered in our database and will be processed manually and automatically according to the Regulation and the national legislation defining the implementation of the Data Protection Regulation.

☐I hereby consent that above mentioned information can be used by Azalea Maritime for data base registration and processing.

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