Admirals Crewing Agency Application Form

Admirals Crewing Agencyoffice@admirals-recruitment.comwww.admirals-recruitment.com

SEAFARER'S APPLICATION FORM - PERSONAL DATA

No. / date: /

APPLICATION FORM NAME SURNAME POSITION

P E R S O N A L D E T A I L SAGE MARITAL STATUS WEIGHT HEIGHT DATEOF BIRTH PLACEOF BIRTH LANGUAGES NATIONALITY NEAREST AIRPORT US VISA

ADDRESS

CONTACT PHONE

NEXT OF KIN (NAME AND ADDRESS)

CONTACT PHONED E T A I L S O F F A M I L Y M E M B E R S

WIFE AND CHILDREN DATE OF BIRTH PASSPORT NO DATE ISSUING AUTHORITYISSUED EXPIRES

D E T A I L S O F P E R S O N A L D O C U M E N T SDOCUMENT NUMBER PLACE OF ISSUE DATE ISSUING AUTHORITY

ISSUED EXPIRESPASSPORTSEAMAN BOOKI.D. CARDMEDICAL CERTIFICATE

D E T A I L S O F L I C E N C E S / C E R T I F I C A T E S(NATIONAL FIRST)CERTIFICATE NUMBER GRADE DATE ISSUED BY

ISSUED EXPIRESROMANIAN

O T H E R: H O B B I E S, I N T E R E S T S, ETC.

C A R E E R D E T A I L SR E C O R D O F P R E V I O U S S E R V I C E

COMPANY RANK SHIP PARTICULARS DATESNAME TYPE DWT MAIN ENGINE FROM TO

Cod doc: F14-01 / 01.01 / 24.08.2015 Operator date personale: 0006421 / 27.03.2014 Pag. 1 / 3

PHOTO



S U M M A R Y O F S E A S E R V I C E(IN MONTHS)RANK OIL TANKER BULK GEN. CARGO RO / RO CONTAINERS OTHERS TOTAL

C O L L E G E S / I N S T I T U T E S, ETC.NAME OF INSTITUTION COURSE ATTENDED DATES QUALIFICATIONS GAINED

FROM TO

A D D I T I O N A L C O U R S E SNAME OF COURSE CERTIFICATE DETAILS

NO. ISSUED AT DATE EXPIRES ISSUED BYSURVIVAL AT SEAFIRE FIGHTINGFIRE FIGHTING ADVANCESURVIVALCRAFTMEDIC. CARE / FIRST AIDMEDIC. CARE ADVENCEDRESCUE BOAT COMMENDERDANGER. CARGO END. P/G/CMARINE POLLUTIONRADAR PLOTTINGARPAGMDSSGOCENGLISH COMMUNICATIONSP.S.S.R.(PERS. SAF. SOC. RESP.)OIL TANKER FAMILIARISATIONOIL TANKER EXPL.SAFETYIN OIL TANKERSCRUDE OIL WASHING (COW)INERT GAS (IGS)BRIDGE TEAM MANAGEMENTGAS TANKER FAMMILIARISATIONSPECIALIZED TRAINNINGFOR LPGSSD-Sarcini specifice de securitate

SUMMARY OF PREVIOUS EMPLOYERS ( REFERENCES )Company Name Phone no. and email address Contact Person




WAGE EXPECTATION(BETWEEN)SIGNEDDATE PLACE

I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge.Also, I agree that the company Admirals Crewing Agency use my personal information only in order to find me an employer (schipowner, vessel) and to facilitate my engagement.Prin prezenta confirm ca toate informatiile transmise de mine in aceast formular sunt adevarate si corecte. De asemenea, conform ca sunt de acord ca firma Admirals Crewing agency să utilizeze informaţiile mele personale pentru a îmi găsi un angajator (armator, navă) şi a îmi înlesni angajarea.

Date / Data Signature / Semnatura


Admirals Crewing Agency Application Form

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