Application for Seagoing Appointment

Applicant Details
Date of
Rank:

Application:

Type of Contract:

Available From:

05/12/2013
Surname:

First Name:

Marriage Status:

Date of Birth:

Place of Birth:

Nationality:

Height (cm):

Weight:

Eye Colour:

Contact Details
Address:

Town/ City:

Country:

Telephone Number:

Postcode:

Mobile Number:

E-Mail Address:

Nearest Airport:

Next of Kin
Surname:

First Name:

Relation:

Address:
Town/ City:

Country:

Telephone Number:

Post Code:

Mobile Number:

Identification
Passport Number:

Date of Issue:

Date of Expiry:

Country Issued:

Seamans Book Number:

Date of Issue:

Date of Expiry:

Country Issued:

Visa Number:

Date of Issue:

Date of Expiry:

Country
Issued:

Type:

Certificate of Competency
Certification Rank:

CoC Number:

Issuing Authority:

Date of Issue/ Revalidation:

Date of Expiry:

Endorsements:

Level Operational

Management

Chemical

Level Operational

Management

Gas

Level Operational

Management

Oil

Please use additional sheets to supply details of further documents which you hold where
there is not enough space provided below

OFPER 1 (Ver. 6 Mar 12)

Medical Certificates
Country:

Type:

Date of Issue:

Date of last Drug and Alcohol Test:

Date of Expiry:

Result:

Expiry Date of Yellow Fever Vaccination:

Training
Please check all the qualifications you hold below and detail their issue and expiry dates.

Personal Safety Techniques:

Basic Safety:

GMDSS General Operator:

Issue:

Issue:

Issue:

Expiry:

Personal Safety & Social

Responsibilities:
Issue:

Advanced Fire Fighting:

Issue:

Expiry:

Fire Fighting and Prevention:

Expiry:

Expiry:

Proficiency in Survival Craft &

Rescue Boats:
Issue:

Expiry:

Issue:

Expiry:

Safety Officer:

Security Officer:

Issue:

Issue:

Expiry:

Expiry:

Expiry:

Medical Care:

Elementary First Aid:

Medical First Aid:

Issue:

Issue:

Issue:

Expiry:

ECDIS:
Issue:

Expiry:

Expiry:

Bridge Team Management:

Hull Integrity:

Issue:

Issue:

Expiry:

Crowd Management:

Crisis Management:

FRAMO:

Issue:

Issue:

Issue:

Expiry:

Expiry:

Ice Navigation:

ISM/ISO Auditor:

Issue:

Issue:

Expiry:

Tanker Familiarisation Training:

Chemical
Gas

Expiry:

Expiry:

Expiry:

Expiry:

Oil

Specialised Tanker Training:

Gas

Oil

DP Induction:

DP Simulator :

DP Operator:

Issue:

Issue:

Issue:

Expiry:

Expiry:

Chemical

Expiry:

Other specialised training certificates held:

Marlins English Test :

Issued at

Issue:

Expiry:

Other languages you are proficient in:

Spanish:

French:

German:

Result:

Italian:

Please use additional sheets to supply details of further documents which you hold where
there is not enough space provided below

OFPER 1 (Ver. 6 Mar 12)

Please fill in full sea time history from beginning of cadetship to current date. Please use additional sheets if necessary.

Sea Time History

Rank

Vessel Type

Vessel Name

Employer

Flag

From

To

DWT

Gross
Tonnag
e

Main Engine
Model

BHP

References

Please provide your most recent employer as your first referee. Contact to current employer will only be made upon
acceptance of a job offer.

Name:

Job Title:
carried:
Officers with experience on
Product/Chemical
tankers please state
Cargoes
Telephone Number:

Email Address:

Company Name:

Address:

Reference:

Please use additional sheets to supply details of further documents which you hold where there is not enough space provided below
Name:

Job Title:

Telephone Number:

Email Address:

Company Name:

Address:

OFPER 1 (Ver. 6 Mar 12)

Reference:

Please fill in full sea time history from beginning of cadetship to current date. Please use additional sheets if necessary.

Sea Time History

Rank

Vessel Type

Vessel Name

Employer

Flag

From

To

DWT

Gross
Tonnag
e

Main Engine
Model

BHP

Officers with experience on Product/Chemical tankers please state Cargoes carried:

Please use additional sheets to supply details of further documents which you hold where there is not enough space provided below

OFPER 1 (Ver. 6 Mar 12)