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DECK CADET
CONTAINER VESSEL
8TH JANUARY 2017
Yes
Internet
Nationality: PERUVIAN
Date of Birth:
01/10/1993
Age:
22
Passport
Number
Place of Issue
Peru
3251414
Date of Issue
Date of Expiry
11/10/2015
11/10/2020
Issuing Authority
IMMIGRATIONS PERU
Seamans Book
Number
Place of
Issue
Peruvian
Date of Issue
11/10/2015
G45L1
Issuing
Authority
COAST
GUARD AND
HARBOUR
Date of
Expiry
11/10/2020
Remark
U.S. Visa
Type
Date of Issue
Date of Expiry
Place of Issue
B1/B2
11/09/2015
11/09/2019
LIMA-PERU
Remark
Education Background
School / College
From
I.E 6048JORGE
BASADRE
NATIONAL SCHOOL
MERCHANT MARINE
To
2005
2010
COLLEGE CERTIFICATE
2013
2017
Personal details
Full address
Str. 2 gpo 24 mz L lte 14
Postal Code:
051
Country:Peru
E-mail:
(required)* renzotipian@gmail.com
Relationship: MOTHER
C/Eng
GMDSS
Issuing Authority
Number
Date of Issue
Date of Expiry
Place of Issue
Grade / Level
I / II
Issuing
Authority
Number
Date of Issue
Date of Expiry
Chemical
Oil
Gas
Place of Issue
Number
LIMA-PERU
HG57H658
LIMA-PERU
LIMA-PERU
LIMA-PERU
LIMA-PERU
JG686HJ8
H77907J
HU89535
First Aid
Medical & First Aid
LIMA-PERU
H798KIBP
LIMA-PERU
JU786J8J7
LIMA-PERU
HU786HHO
LIMA-PERU
LIMA-PERU
KI87KJ780
Date of Expiry
JHY697H7
ARPA
Radar Simulator
Date of
Issue
KJ685GR
Page 2
Employment History
*
Vessel
E
x
p
e
i
e
n
c
e
d
Company
Vessel
Type
Flag
DWT/
TEU*
Year
Built
Main Engine
Make
Type
Page 3 of 5
B.H.P.
**
Rank
Sign on
date
Sign off
date
Total
mm/dd
Reason for
leaving
r
Weight: 72
Safety shoes: 42
Boiler suit: 32
Distinguishing Marks :
A beauty mark on my left side of my cheek
References
Do you have any objection if we will contact your last employers for reference
Reference?
If NO please specify below:
Yes
Please give the name and address of your current or immediate past employer
Name of company
Name of person to contact
Address
No.
Banks Name:
Banks Address:
Banks Name:
Type :
Current / Savings
Date of Expiry
22/11/2016
07/11/2017
Page 4
Date of Expiry
22/11/2016
05/11/2017
Medical History
Have you ever signed off from a ship due to Medical reasons?
(If Yes give details)
No
Name of Vessel
Date of Occurrence
I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge
and belief; further, that no Certificate of competency or License issued to me has ever been Revoked or Suspended. I
also certify that my medical history contained above is true and any false statement or undisclosed Material information
about past illness or injury will disqualify me from any employment benefits and claims.
Date _11.10.2007__________
_______________________
Signature
APM id no:
Page 5