/ FURTRANS
TANKER & SHIP
MANAGEMENT / Safety, Quality, Health and Environmental Department / Page:of:
13
Application form
La presente application non costituiscepromessa d’ imbarco
The present does not imply future embarkation / Release:
0
Document may not to be disclosed to any third party without the prior approval of the management.
Applicant’s Surname: / Applicant’s First Name:
Rank: / Date of birth: Age: / Place of birth:
Home address:
Telephone: / Email:
Available from:
Marital Status: / Single / Married / Next of kin: / Telephone:
DOCUMENTS / NUMBER / ISSUING AUTHORITY / Date Issued / Expiry Date
Passport
Seaman’s book
National COC
S T C W Endorsement
Flag Endorsement
Medical Fitness Certificate
TRAINING CERTIFICATES / YES / NO / ISSUING AUTHORITY / Date Issued / Expiry Date
IMO Deck Officer (A-II/1)
IMO Ch. Mate (A-II/2)
IMO Master (A-II/2)
IMO Deck Wachkeeping (A-II/4)
IMO Engine Officer (A-III/1)
IMO 1ST Eng. (A-III/2)
IMO Ch. Eng. (A-III/2)
IMO Engine Wachkeeping (A-III/4)
Cook ability certificate
Sanitary certificate / HACCP fam.
Survival (A-VI/1-2 1.1)
TRAINING CERTIFICATES / YES / NO / ISSUING AUTHORITY / Date Issued / Expiry Date
Basic Fire Fighting (A-VI/1-2 1.2)
Elementary First Aid (A-VI/1-2 1.3)
P.S.S.R( A-VI/1-2 1.4)
Advance Fire Fighting ( A-VI/3)
First Aid (A-VI/4.1)
Medical Care (A-VI/4.2)
ARPA (A-I/12-5)
RADAR (A-I/12-4)
RADAR ARPA SAR (A-I/12)
GMDSS (A-IV/2)
Oil Tanker Safety
Chemical Tanker Safety
Oil Tanker Familiarization
Chemical Tanker Familiarization
Survival Craft (A-VI/2)
Ship Security Officer
Additional Certificate required by Company
Ecdis Specific Course
Ecdis General Course
Bridge Team Management Course
Ship Handling Course
Safety Officer
Incident Training Course

PREVIOUS SEA SERVICE - MINIMUM LAST THREE YEARS

COMPANY / VESSEL / RANK / TYPE / FLAG / DWT / ENGINE TYPE / FROM / TO / REASON FOR SIGNING OFF
B/C / Bulk Carrier / FPSO / FloatgProdStorOffldg / MLP / Multi-purpose / PAS / Passenger Ship / YAT / Yacht
CON / Cellular Container / GCD / General Cargo / MSV / MultiServiceVessel / RFG / Reefer Vessel / TNB / Tanker(Bitumen)
CHM / Chem Carrier IMO I-II / HLV / Heavy Lift Vsl / NVL / Naval Ship / R/R / Ro/Ro Carrier / TNC / Tanker(Crude)
CH3 / Chem Carrier IMO III / LSH / Lash / RIG / OffShore Oil Rig / PRR / RoRo-Pax / TNP / Tanker(Products)
DRG / Dredgers / LIV / Live Stock Carrier / OSV / OffShore Supply Vsl / SAL / Sailing Vsl / TNS / Tanker(Storage)
DP / Dynamic Positioning / LNG / LNG Carrier / OBO / Ore/Bulk/OilCarrier / SRV / Survey Vessel / TNV / Tanker(vlcc/ulcc)
FSH / Fishing Vsl / LOG / Log/Timber / O/O / Ore/OilCarrier / SUL / Self-Unloader
FSO / FloatingStorageOffldg / LPG / LPG Carrier / OTH / Other / TUG / Tug
Created by: / Checked by: / Instructed by
Safety, Quality, Health and Environmental Dept.
09/04/2013 / Designated Person Ashore
09/04/2013 / Managing Director
09/04/2013