Sevastopol branch office:

5A, Rybakov Str.,office 102 ,Sevastopol, Crimea region, 299014, Russian

Federation
Tel: +7(978) 0209692 mail for CV: cv@seagengroup.com

Position Applied For Manning Office Foto

Requested Wages Date of Availability

PART I. PERSONAL DESCRIPTION AND INFORMATION:

1. FAMILY NAME 2. FIRST NAME 3. FATHER NAME

4. DATE OF BIRTH 5. PLACE OF BIRTH 6. NATIONALITY 7. HEIGHT 8. WEIGHT 9. COLOUR OF EYES

10. SHOES SIZE 11. WORKING CLOTHES SIZE 12. HAIR COLOR
CITY COUNTRY ADDRESS
13. HOME
ADDRESS:
14. SKYPE NAME 15. MOBILE 16. E-MAIL 17. MARITAL STATUS

PART II. NEXT OF KIN

LAST NAME NAME RELATIONSHIP TELEPHONE
18. NEXT OF
KIN
CITY COUNTRY ADDRESS
19. N.O.K.
ADDRESS:
PART III. PASSPORTS
PASSPORTS NUMBER PLACE OF ISSUE ISSUED ON VALID TILL
National passport
Seaman's Book
International Travel Passport
PART IV. VISAS
VISA NUMBER VALID TILL VISA NUMBER VALID TILL
USA
SCHENGEN
GERMAN (WORKING)
PART V. NATIONAL CERTIFICATES OF COMPETENCY
LICENSE CAPACITY (REGULATION) NUMBER PLACE OF ISSUE ISSUED ON VALID TILL
Certificate of Competency
Certificate of Competency
PART VI. CERTIFICATES
CERTIFICATE NUMBER VALID TILL CERTIFICATE NUMBER VALID TILL
Med. Examination GMDSS (R.O.C. / G.O.C.)
Yellow Fever Endorsement of GMDSS
Basic Safety Training ARPA
Proficiency in Survival Craft Radar Observer
Advanced Fire Fighting Medical Care
Medical First Aid Ship Security Officer (S.S.O.)
HAZMAT Ships Safety Officer (ISM Code)
Designated Security Duties Bridge Team Management
Security Awareness Training ECDIS

Tankers Familiarization ERTM

Oil Tanker Specialized
Chemical Tanker Specialized
Liquefied Gas Tanker Specialized
Crude Oil Washing
Inert Gas System
High voltage certificate
PART VIII. FLAG STATE DOCUMENTS
DP Advance Course FLAG DOCUMENT GRADE ISSUED ON VALID TILL
DP Full Limited SB
MARSHAL.I
DP Full Unlimited Endorsement
DP Maintanance SB
A.BARBUDA
HUET/BOSIET Endorsement
H2S SB
LIBERIA
HLO Endorsement
PART XI. DETAILS OF PREVIOUS SEA SERVICE
YEAR OF POWER, CARGO PERIOD OF SERVICE
RANK NAME OF VESSEL FLAG TYPE OF VESSEL DWT TYPE OF ENGINE SHIP OWNER / MANAGER
BUILT kW GEARS FROM TO

PART XII. REFERENCE VERIFICATION RESULTS

COUNTRY / EVALUATION SUITABLE FOR
ORGANIZATION NAME OF ORGANIZATION TELEPHONE P.I.C. REEMPLOYMENT REMARKS
CITY ABILITY SOBRIETY DILIGENCE (YES/NO)

SHIP OWNER / MANAGER

1
MANNING AGENT

SHIP OWNER / MANAGER

2
MANNING AGENT

SHIP OWNER / MANAGER

3
MANNING AGENT

PART XIII. INTERVIEW NOTES

INTERVIEW DATE INTERVIEWED BY LEVEL OF ENGLISH APPEARANCE EXPERIENCE WITH MULTINATIONAL CREW (LIST NATIONALITIES)

INTERVIEWER REMARKS

PART XIV. DECK DEPARTMENT

CONTAINERS, MAX. TEU BULK (LIST CARGOS) GENERAL CARGO (LIST CARGOS) HEAVY-LIFT CARGO (LIST CARGOS) PROJECT CARGO (LIST CARGOS)

TRADE AREAS NOTES

PART XV. ENGINE DEPARTMENT

H.F.O., GRADE 4-STROKE ENGINES (LIST TYPES) 2-STROKE ENGINES (LIST TYPES) PURIFIERS WELDING SKILLS TURNING SKILLS CRANE/DERRICK TYPES
 AGREEMENT

I hereby declare that the above is true. I further consent to the holding and processing by you and any of your
direct or indirect parent or subsidiary or associated or affiliated companies (hereafter the "Company") and your
or Company's principals of personal data about me for all purposes related to my application for employment
on board vessels managed by the Company or vessels owned or operated by third parties for whom the
Company is engaged to provide crew. I understand that this data will be stored in your databases in relation to
my actual or potential employment by or through the Company. Further, I confirm that the above may involve
the transfer of my personal data within the Company or to third parties worldwide.

______________________ ______________________ /_______________________________/

Date Signature Full name