NAVIGATOR

SEAMAN’S APPLICATION FORM
DATE APPLIED RANK APPLIED
___ / ___ / ______/
PHOTO
1. FAMILY NAME /
FIRST NAME
/
CONTACT DETAILS
Home Phone:……………………
Mob: ………………………….
E-mail:…………………………..
2. FATHER’S NAME /
MOTHER’S NAME
/
WIFE’S NAME
3. PLACE OF BIRTH /
DATE OF BIRTH
/ AGE HEIGHT(cm) WEIGHT(Kg)
4. NATIONALITY / /
HAIR COLOR EYES COLOR
5. LICENCE CLASS /
LICENSE NO. / DATE OF ISSUED
/
EXPIRY DATE
6. SEAFARER’S ID /
DATE ISSUED
/
EXPIRY DATE
7. PASSPORT No. /
DATE ISSUED
/
EXPIRY DATE
8. USA VISA /
DATE ISSUED
/
EXPIRY DATE
9. BRAZILIAN VISA / EXTENSION

VALID: YES NO /
DATE ISSUED………………………….
DATE ENTERED BRAZIL……………..
/
DATE VISA REGISTERED……………….
10. MARRIED OR SINGLE /

CHILDREN (NAMES)

1.
2. /

SEX (M-F)

1.
2. /

DATE OF BIRTH

1.
2.
11. PERMANENT ADDRESS
(ADDRESS + POSTAL CODE)
12. NEXT OF KIN CONTACT
DETAILS / FULL NAME: RELATIONSHIP:
Tel. Number
13. EDUCATION: / SCHOOL / COLLEGE ATTENDED / FROM TO / GRADE NO.
14. ENGLISH SPEAKING / POOR / GOOD / FLUENT
RECOMMENDATION:

MEDICAL BACKGROUND

/ YES NO (If yes, please briefly describe)

ANY PREVIOUS SURGERY?

ANY PREVIOUS SERIOUS ILLNESS?

ANY PHYSICAL HANDICAP?

ANY DRUG RELATED PROBLEM ?

ANY ALCOHOL RELATED PROBLEM ?

PREVIOUS EVENT HISTORY

HAVE YOU BEEN INVOLVED (DIRECT OR INDIRECT) TO ANY

ACCIDENT OR POLLUTION INCIDENT? (IF YES PLEASE SPECIFY)

/ YES NO

BRIEF DESCRIPTION OF THE INCIDENT (IF ANY)

NAVIGATOR

NAME: / RANK: / VESSEL :
STCW '95 Minimum Certificates/Licenses/Endorsements/Training Requirements Per Position / OIL/ CHEMICAL TANKERS-CHECKLIST
TANKERS / Issued date / Expire date / Remark / MASTER / CHOFF / 2OFF / 3OFF / BSN / PMAN / A/B / O/S / D/CADET / CHENG / 2ENG / 3ENG / 4ENG / ELECTR / OILER / WIPER / FITTER / E/CADET / C/COOK / 2COOK / MMAN
LEVEL / MANAGEMENT / OPERATIONAL / SUPPORT / MANAGEMENT / OPERATIONAL / SUPPORT / CATERING
A.1 / Seaman's Book National / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
A.2 / Vessel's Flag Seaman's Book / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
A.3 / Medical Card / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
A.4 / Passport / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
A.5 / Visa Usa / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O
A.6 / Brazilian Visa / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O / O
A.7 / D & A Test / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
A.8 / Yellow Fever / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
STATUTORY CERTIFICATES - STCW'78/95
B.1 / Certificate of Competence COC / National Licence / Class(1,2,3)…… / II/2 / II/2 / II/1-II/2 / II/1-II/2 / II/4 / II/4 / II/4 / III/2 / III/2 / III/1-III/2 / III/1-III/2 / ELEC / III/4 / III/4 / M
B.2 / Vessel's Flag CRA Certificate- For Non National Flag vessel-(3M) / M / M / M / M / M / M / M / M / M / M / M / M / O
B.3 / Flag's Endorsement Certificate-For non National Flag vessel / M / M / M / M / M / M / M / M / M / M / M / O
B.4 / Basic Safety Training (BST) ( VI/1-1, VI/1-2, VI/1-3, VI/1-4 ) / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
B.5 / Proficiency in Survival Craft & Rescue boat (PSCRB) (VI/2-1 ) / M / M / M / M / M / M / M / M / O / M / M / M / M / M
B.6 / Proficiency in Fast Rescue boat (PFRB) (VI/2-2 ) * / O / M
B.7 / Advanced Fire Fighting (AFF ) ( VI/3-1 ) / M / M / M / M / M / M / M / M
B.8 / Medical Emergency First Aid ( MEFA ) ( VI/4-1 ) / M / M / M / M / M / M / M / M
B.9 / Medical Care ( MC ) ( VI/4 par. 4-6 ) / M / M
B.10 / Navigational Watch Keeping / M / M / M / O
B.11 / E/R Watchkeeping / M / O
B.12 / General Tanker Familiarization Course - GTF - ( V/1-1 ) / O / O / M / M / M / M / M / M / O / O / O / M / M / M / M / M / M / O / M / M / M
B.13 / Specialized Training Oil Tanker- STOT ( V/1-2 par.8-14 ) - (5Y) / M / M / 0 / 0 / 0 / M / M / M / 0 / 0
B.14 / Specialized Train. Chemical Tanker-STCT (V/1-2 par.15-21) ** / M / M / 0 / 0 / 0 / M / M / M / 0 / 0
B.15 / GMDSS Radio Operators IV/2 / at Least 2 D/Off / M / M / M / M
B.16 / Arpa Certificate / M / M / M / M
B.17a / ECDIS Certificate (Generic) Reg.II/1 par:2.5 sec A-II/1 **** / M / M / M / M
B.17b / ECDIS certificate (Type Specific)**** / M / M / M / M
B.18 / Ship Security Officer Certificate - reg. VI/5 - ( SSO ) / M / M / M / M
B.19a / Security Awareness Reg.VI/6, Sec A-VI/6 (par 1-4)***** / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
B.19b / Designated Security Duties Reg.VI/6, Sec A-VI/6 (par 6-8)***** / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M / M
NON - STATUTORY CERTIFICATES
C.1 / Safety Officer Certificate ( SOC ) *** / O / M
C.2 / Bridge Team/Resourse Management-B-I/12 p.36-38-(BTM/BRM)*** / M / M / M / M
C.3 / Engine Resource Management A-VIII/2 & B-VIII/2 (ERM)*** / M / M / M / M
C.4 / Ship Handling *** / M
C.5 / Risk Assessment *** / M / M / M / M
C.6 / Incident Investigation *** / M / M / M / M
1 / * -Is required for vessels with fast Rescue boats
2 / ** -Is required for Chemical vessels / O: / Optional / Checked by :
3 / * * * -Refresh Course every (4) Yrs / M: / Mandatory / Date :
4 / * * * * -For vessels where ECDIS is fitted and Approved
5 / * * * * * -If A-VI/6 par 6-8 on hands, par 1-4 Not Required
6 / B.3 covers requirements of B.2
7 / B.13 (STOT) & B.14(STCT) covers requirements of B.12 (GTF)

NAVIGATOR

Certificates, diplomas, seminars, etc (other than those specified in the above table). / Issued by / Issue date
Certificates, Diplomas, Seminars, etc. for DP Vessels
Senior DPO / Junior DPO / Trainee DPO / Electric Engineer
DP Unlimited / DP Advanced / DP Basic / HIGH Voltage
Offshore Loading Phase I / DP Maintenance
Offshore Loading Phase II / ARTEMIS Maintenance Course
Offshore Loading Phase III (Refresh Every 2 Years) / DGPS/DARPS Maintenance Course
ARTEMIS Operator Course / FAN BEAM Maintenance Course
DGPS/DARPS Operator Course / BLOM PMS System Maintenance Course
FAN BEAM Operator Course
BLOM PMS System Operator Course
Does the applicant hold all statutory certificates listed in the above table? / YES / NO
Does the applicant hold all non-statutory certificates listed in the above table? / YES / NO / N/A
If NO list the non-statutory certificates the applicant does not hold (training needs):
C.E.S Completed? (score achieved should be minimum 50%) / YES / NO / N/A

SEA SERVICE OF LAST YEARS(Please start with the last service)

Company’s Firm / Vsl’s
Type /

Name

/ Flag / Dwt / BUILT / ENG/BHP / Rank / Service Duration / Total
Months / Reason of S/Off
From To
Cargoes carried the last years:
I certify that the above information is true and correct.
I fully understand and agree that any false declaration herein above shall result in instant dismissal without any responsibility or liability whatsoever on the part of the company.
А также даю свое согласие на обработку моих персональных данных согласно ФЗ
« О персональных данных » от 27.07.2006 № 152-ФЗ.

Date Signature of Applicant
FOR OFFICIAL USE ONLY (Do not write here)

MANNING AGENT / CREW MANAGER APPLICATION REVIEW (application’s validity to be reviewed prior each employment)

MANNING AGENT(NAME / SIGNATURE): / DATE /

CREWING MANAGER(NAME / SIGNATURE):

/

DATE