/ Applicant's Questionnaire / PRC.09-F1
Version:1.0

Translation from the Latvian language into the English language

You were interested in the opportunity to work at MARITIME INDUSTRIES LTD.

Therefore, please complete a job interview questionnaire by providing honestanswers to the

questions given below. Read a question carefully before providing an answer, in case you find

it unclear, feel free to ask the interviewer, what has been asked in that question.In case the

answers are already provided, please circle the corresponding option.This questionnaire is

confidential and the information provided in it will be used only for recruitment purposes of

MARITIME INDUSTRIES LTD.

Note: The questions marked with * starare not obligatory

Rank applied for: / Available on:
Surname: / Forenames:
Date of Birth: / Place of Birth: / Citizenship:
Personal Code: / Sex: / Marital Status:
Address:
City Country:
Phone (including code): / Mobile phone:
E-mail:
*Bank details and account No.

Next in kin

Surname: / Forenames:
Address (if not same as above):
City Country:
Phone (including code): / Mobile phone:
E-mail:

*Why did you leave / would leave theprevious employment? ______

______

EDUCATION

Name of School attended / Address (City) / Speciality / Graduated (Date)

* Why did you choose this educationestablishment? (Mention several reasons)______

______

DOCUMENTS/CERTIFICATES

Documents: / Type / Grade / Number / Place of issue / Date of issue / Expire date
Passport / National / xxxxx
Other / xxxxx
Seamans
book / National / xxxxx
Panamanian / xxxxx
Other / xxxxx
Licence
Information / National
Endorsement (National)
Panamanian
Other:
Other certificates / SOLAS (basic) / A-VI /1- 1, 2, 3, 4
Proficiency in Survival Craft / A-VI / 2-1
Fast Rescue Boat / A-VI / 2-2
Advanced Fire Fighting / A-VI / 3
First Aid / A-VI / 4-1
Medical Care / A-VI / 4-2
Radar/ARPA
GMDSS
GMDSS Endors
Ship Security Officer / A-VI / 5
Security Awareness (for all) / A-VI/ 6-1
Security training (with designated duties) / A-VI/ 6-1; A-VI/6-2
AMOS
Bridge Team Management
ER Resource Management
Ship's Handling
ECDIS (Electronic Charts)
Passengers ship / A-V/2.1 ,2,3,4
Marlins Test
Dangerous
Cargo
Endorsements / Oil, Chemical, Liquid Gas tanker Familiarization / A-V / 1 (p.1-7)
Petroleum
Chemical
HAZMAT
Crude Oil Washing
Inert Gas
Medical Fitness Cert / National
Other

Additional education, courses Where? When? For how long?

  1. ______
  2. ______
  3. ______
  4. ______

* work experience with computer ______What kind of computer programsdo you work with?______

______

______

Language knowledge (evaluate according the following system: 5-mother tongue, 4-fluent, 3-good, 2-deficient, 1-poor)

LanguageLevelHow did you acquire this language?

  1. Latvian ______
  2. Russian______
  3. English ______
  4. ______

Your the latest employers contacts: ______

______

Work experience

COMPANY / CREWING / Vessel name / Flag / Type / G.T. / Eng Type/ Power / Rank / Date On / Date Off

Please markoverall SIZE and HEIGHT in accordance with the table

Size / 44 / 46 / 48 / 50 / 52 / 54 / 56 / 58 / 60 / 62 / HEIGHT / HEIGHT / sleeve / Trouser
Chest / 88 / 92 / 96 / 100 / 104 / 108 / 112 / 116 / 120 / 124 / I / 158-164 / 56 / 94
Waist / 70 / 76 / 82 / 88 / 94 / 100 / 106 / 112 / 118 / 124 / II / 164-170 / 59 / 98
Hip / 94 / 98 / 100 / 104 / 108 / 112 / 116 / 120 / 124 / 128 / III / 170-175 / 62 / 102
IV / 175-180 / 65 / 106
Shoes Size / V / 180-185 / 68 / 110
VI / 185-190 / 71 / 114
VII / 190-195 / 74 / 118
VIII / 195-200 / 77 / 122

Date of completion of the questionnaire______place______signature______

Thank you for the information provided,

the managementof MARITIME INDUSTRIES LTD
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