APPLICATION FORM
Tel: +370 46 300266 E-mail: [email protected]
GSM: +370 699 42482 ; +370 655 50528
Web: www.sailinga.lt
PERSONAL DATA
Position applied for:
Surname:
Name:
Personal number:
Date of birth:
Place of birth:
Adress:
Phone:
E-mail:
CERTIFICATES OF COMPETENCY
Certificates
STCW
Number
Place of
code
issue
Certificate of competence
Endorsement
SOLAS Basic safety course
VI/1
Survival craft and rescue boat
VI/2-1
Proficiency in fast rescue boat
VI/2-2
Advanced fire fighting
VI/3
Medical first aid
VI/4-1
Medical care
VI/4-2
Radar observation
I/12
Automatic Radar Plotting Aids
I/12
GMDSS
IV/2
Tankerman familiarization
V/1
Tankerman Chemical
V/1
Tankerman Oil
V/1
Tankerman Gas
V/1
Bridge Team Management
VIII,II/2
Crowd Management
V/2,3
Maneuvering and ship handling II/2,V/a
Ship security officer
XI-1,2
ECDIS
II/1,2
DP-Basic
DP-Advanced
Date of
issue
Date of
expire
Fair
Poor
Health Certificate
PASSPORTS AND VISAS
National Passport
Seaman’s Book
Other Seamen’s Book
Other Seamen’s Book
US Visa C1/D
ENGLISH LEVEL
REMARKS
VGood
Good
Satifact.
FOR OFFICE USE
SEA SERVICE (Please submit your service at sea during last five years)
Name of
Type of
Flag
GRT
Type of
Vessel
Vessel
Engine
OTHER INFORMATION
Minimum salary (EURO):
Marital status:
Name, address and phone of
next of kin:
Height:
KWT
Owners or
Managers
Rank
Sign-on
dd.mm.yy.
Maximum contract period:
Available from:
Number of children (up to 18):
Weight:
Color of eyes:
Color of hair:
Sign-off
dd.mm.yy.