Navigare Management Application Form

/ NAVIGARE MANAGEMENT / Form: NM-CRW-001

Navigare Management Application Form

1. Personal Data

Photo / Surname / Readiness:
Name / Last salary:
Father's Name / Remarks:
Permanent address:
Citizenship
Date of birth
Place of birth
Phone:
Mobile:
E-mail:
SKYPE
Document / No. / Date of issue / Placeof issue / Valid until
Passport (Travelling)
Seaman’s Book
Ukrainian Civil Passp.
Liberian S. B.
Panamanian S. B.
Singapore
Other

2. Visas

Country / Visa Type/Class / No. / Date Issued / Place Issued / Valid Until
USA
Australia
Singapore
SCHENGEN

3. Marine Education

Full Name of School / Qualification / From / Till

4. Sea experience

№ / Rank / Vessel / Flag / DWT / Type of
vessel / Owner or Management Co /Country / From / To / Reason of departure
1
2
3
4
5
6
7
8
9
10
11
№ / Automation
(A1/A2) / Main Engine
Maker / Model / Engine
Stroke / Engine
Total
HP/KW / Aux. Engine
Maker / Model / Aux. Engine
HP/KW / Experience / Crew
Unmanned Yes/No / With El.Eng Yes/No
1
2
3
4
5
6
7
8
9
10
11

5. Highest Competency certificate held:

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

6. Certificates/Courses

Certificates of STCW 78/95 / Number / Date of issue / Place / Expiry date
Basic Safety Training and Instruction (A-VI/1)
Carrying Dangerous & Hazardous cargo (B-V/b, B-V/c)
Advanced Fire Fighting (A-VI/3)
Proficiency in Survival Craft, Rescue Boats (A-VI/2-1)
Medical First Aid (A-VI/4-1)
Medical care (A-VI/4-2)
ARPA
Ship safety officer IMOA 741(18)
Ship Security Officer (STCW A – VI/5 and ISPS Code)
Security Awareness (A-VI/6-1)
Designated Security Duties ( A-VI/6-2)
GMDSS
Bridge team management
Process Control Instrument
Radar navigation
Risk Assessment
ECDIS
Ice Navigation
Incident Investigation & Analysis
Ship Handling and Manoeuvring
Tanker Certificates / Number / Date of issue / Place / Expiry date
Chemical Tanker Advanced
Liquefied gas Tanker specialized training (A-V/1, c. 22-34)
Oil Tanker Avanced
Crude oil washing (STCW 3/9)
Inert gas system (MARPOL 73/78)

7. Additional information

English language

/ Excellent / Good / x / Satisfactory / Poor
Computer proficiency / Excellent / Good / x / Satisfactory / Poor
Bank details
Next of Kin
Marital Status
Overall, height, weight, shoes size
Medical Certificates included yellow fever, cholera
Nearest airport
English - Marlin/Ces 4.1 tests

Please complete addresses of your previous employers for references

Company / Tel.: / Company / Tel.:
Address / Address

I certify that above information is true and accurate to the best of my ability and that no Certificate of Competency, Licenses or Visas issued to me has ever been revoked or suspended.

I have been advised and agree to recover expenditure of Shipowner and/or Crewing Agency, which can be occurred due to wrong information or faulty documents from me.

I understand that previous employers may be asked for information concerning my Employment record with them and I hereby release from all liability or damage those individual or companies who provide such information

Я, , в соответствии с Законом Украины «О защите персональных данных» от 01.06.10 №2297-VI, даю свое согласие на включение моих персональных данных ООО «Навигаре Манаджмент» в виде картотеки и/или автоматизированной информационной системы, а также на их обработку (сбор, регистрацию, накопление, бессрочное хранение, изменение, обезличивание, уничтожение, обновление, адаптацию, использование, распространение, реализацию, передачу в полном объеме или частично распорядителям или третьим лицам) без дополнительного письменного уведомления об этом в мой адрес, с целью оказания предприятием посреднических услуг по моему трудоустройству на судах отечественных или иностранных судовладельцев, независимо от страны их местонахождения.

Я письменно уведомлен о включении моих персональных данных ООО «Навигаре Манаджмент», о ее местонахождении и целях сбора данных, о лицах, которым будут передаваться мои персональные данные и о моих правах в связи с этим

Seaman 2017 (signature)