(Passport Photo)

Can be scanned / sent

separately
SEAFARER'S APPLICATION FORM - Page 1 of 4 - PERSONAL DATA
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT-PAGINA 1 DIN 4 DATE
PERSONALE)
PERSONAL INFORMATION ( DATE PERSONALE)
Family Name (Nume)

First Name (s) (Prenume)

Birth Date (Data Nasterii)

Birth Place (Locul nasterii)

Nationality (Nationalitate)

Religion (Religie)

Marital Status (Starea civila)

No. of Children (Nr copii)

Height (cm) (Inaltime)

Weight (kg) (Greutate in Kg)

Nearest Airport
(Cel mai apropiat aeroport int.)
ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any)
ADRESA (incluzand nr telefon, tara si cod zona, a doua adresa sau adresa de contact , daca este cazul )
Street & Nr. (Strada si Numar)
Email Address (Adresa Email)
Location (Localitate)

Mobile Phone (Tel mobil)

City (Oras)

Residence Phone (Tel fix)

State, Country (Tara)

Fax (Fax)

Postal (ZIP) Code (Cod)

P.O. Box (if any) (CP)

NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary)
RUDA CEA MAI APROPIATA/ IMPUTERNICITA ( persona de contact in caz de urgenta si beneficiarul asigurarilor )
Family Name (Nume)
First Name(s) (Prenume)
Nationality (Nationalitate)
Street & Nr. (Str. si Nr.)

Relationship (Grad de
rudenie)
Email Address (Adresa email )

Location (Localitate)

Mobile Phone (Tel mobil)

City (Oras)

Residence Phone (Tel fix)

State, Country (Tara)

Fax (Fax)

Postal (ZIP) Code (Cod)

P.O. Box (if any) (C.P)

REMARKS(REMARCI)
Requested Rank(s)
(Functie)
Prefer Vessel Types (Tip de
nava preferat)
Employment Preference

Availability Date (Disponibil

din)
Minimum Salary(Salariu
minim)

English Language Skills (Limba engleza/ Nivel cunoastere)

Other Foreign Languages (Alte limbi straine)
Professional School / Academy - Name & Period (From - To)
(Scoala / Nume/ Perioada)
Foreign Crew Experience (specify nationalities)
Experinta cu echipaje straine (specificati nationalitatile)
Other Skills
(Alte calitati profesionale)
Further Remarks
(Alte remarci)
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge.
Prin prezenta confirm ca toate informatiile date de catre mine in aceast formular de applicare sunt adevarate si corecte

SEAFARER'S APPLICATION FORM - Page 2 of 3 - LIST OF

DOCUMENTS
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT - PAGINA 2 DIN 4 LISTA
DOCUMENTELOR)

Family Name
First Name(s)
Rank
(Nume de familie)
(Prenume)
(Functie)
A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES(DOCUMENTE DE CALATORIE/MEDICALE )
Document Name (Desciption)
Document Number
Country
Issue Place
Titlul documentului ( Descriere)
Numar Document
Tara
Locul
eliberarii
Passport (Pasaport)

Issue Date
Exp. Date
Data eliberarii Data expirarii

Seaman's Book (national) (Carnet Marinar)

Seaman's Book (Norwegian) (Carnet NIS) (flag state)
Seaman's Book (Liberian) (Carnet Liberia ) (flag state)
Visa - United States (type C1/D) (Viza USA)
Visa - Others (Work/Resid. Permits) (Alte Vize)
Medical Examination Report (Raport Medical)
Offshore Medical (UKOOA, ENG1)
Vaccination against Yellow Fever (Vaccin Febra Galbena)
Vaccination against Cholera ( Vaccin Holera)
Drug & Alcohol Test (Test Drog/ Alcool)
B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES
CERTIFICATE DE COMPETENTA & ENDORSEMENTS , CURSURI
- deck & engine certificates & endor- radio certificates & endorsements
sements (officers / ratings)
- safety training (surv., fire, medical)
- electrical & reefer certificates
- tanker courses (oil, chem., gas)
- cook & steward certificates
- passenger vsl, roro, hazmat courses
Document Name (Desciption)
Document
Country
Titlul documentului (Descriere)
Number Numar
Tara
Document
CERTIFICATE of COMPETENCY
ENDORSEMENT
DYNAMIC POSITIONING BASIC
DYNAMIC POSITIONING ADV.
DYNAMIC POSITIONING LICENCE
HUET
BOSIET
RADAR ARPA
GMDSS (GOC)
MARPOL
DANGEROUS CARGO
BASIC/ADVANCED FIRE-FIGHTING
PERSONAL SURVIVAL TECH.
PROFIENCY SURVIVAL CRAFT AND RESCUE BOATS
PERSONAL SAFETY AND SOCIAL RESP. ON BOARD
MARITIME ENGLISH
ECDIS
SHIP SECURITY OFFICER
BRG/ENG TEAM MANAGEMENT
SHIP HANDLING
ELEMENTARY FIRST AID / MEDICAL FIRST AID
MEDICAL CARE
PREVENTION OF MARINE POLLUTION ON SHIPS:
TRANSPORT AND HANDLING OF DANGEROUS
CARGOES
TANKER FAMILIARIZATION

- deck, technical & management

courses (radar/ARPA, ISM, Marpol,
simulators, computer, welding etc.)
- Dynamic Positioning Experience
Issue Place
Issue Date
Exp. Date
Locul eliberarii Data eliberarii Data expirarii

RO-RO PASSENGER SHIPS

Please indicate your sea service in the last 10 years as exactly as possible - required are the actual sign-on and sign-off dates according to the service certificates resp. seaman's
book entries. To speed up processing kindly indicate phone and/or fax numbers of your previous employers. Ship sizes are to be indicated in gross tons, total engine output in kilo
Watt (1 kW = 1.34 bhp) to go along with STCW limitations. Please attach evidence for the listed sea service (copies of seaman's book entries, service certificates etc.). The
information provided may be passed on to our clients and to flag state administrations to allow for verification of rank experience. Please use the European date format (DD.MM.YY).
SEAFARER'S APPLICATION FORM - Page 3 of 4 - SEA SERVICE (LAST 10 YEARS)
Family Name(Nume):
Vessel's Name
(Numele Navei)

Date
Data:

First Name(s) (Prenume):

Flag
(Pavilion)

GT
(GRT)

kW
(Kw)

Signature
Semnatura:

Ship Type
Eng.Maker
(Tipul Navei) (Motor Principal)

Date of Birth(Data Nasterii):

Rank
(Functie)

S/On Date
(Data
ambarcarii)

S/Off Date
(Data
debarcarii)

Employer (company to contact for

reference)