APPLICATION FOR TECHNICAL STAFF EMPLOYMENT
(PLEASE FILL IN USING BLOCK LETTERS)
Positions applied for
PHOTO
Salary desired
(USD per month)
NAME
SURNAME
Date of birth
Citizenship
(Nationality)
Height (cm)
Weight (kg)
Home Address
Place of birth
Marital status
..........
Number of children under 18 years
(incl. post code)
Contact Phones
Next of kin name
Next of kin’s address
Native
Language:
Relation to you
English
fluency:
DOCUMENT
Travel Passport
Seaman’s Book
Valid U.S. Visa
Certificate of competency # 1
for Rank / Capacity
Endorsement of certificate # 1
Certificate of competency # 2
for Rank / Capacity
Endorsement of certificate # 2
CERTIFICATE
..........
Marlins
Test Score:
PASSPORTS and CERTIFICATES
NUMBER
Issued on
Valid till
Place of issue
..........
VALID UNTIL
CERTIFICATE
Basic Safety Training (SOLAS)/ A-VI/1-1,2,3,4
Proficiency in Survival Craft/ A-VI/2-1
Proficiency in Fast Rescue Boats/ A-VI/2-2
Advanced Fire Fighting/ A-VI/3
Medical First Aid / A-VI/4-1
Medical Care Onboard / A-VI/4-2
Crowd Management ( RO-RO ships) A-V/2
Crowd Management (other than RO-RO ships) A-V/3
Crisis Management ( RO-RO ships) A-V/2
Crisis Management (other than RO-RO ships) A-V/3
Ship Safety Officer/ SOLAS 74 XI-1, IMO 3.19
Ship Security Team/ SOLAS XI-1, XI-2
SEAMAN’S BOOK (by Country)
List any other
languages:
VALID UNTIL
GMDSS Certificate / Endorsement
ARPA
Radar Observation and Plotting
Ship Handling Arrangements
Dangerous & Hazardous Cargoes
Maintenance of El./Electronic Eng.
Gas Tanker Specialized Training
Chemical Tanker Special. Training
Tanker Familiarization Course
Oil Tanker Specialized Training
Crude Oil Washing
FOREIGN SEAMAN’S ID / RECORD BOOKS
NUMBER
ISSUE DATE
EXPIRATION DATE
ADDITIONAL INFORMATION
1. Have you ever been refused US visa? If yes, when and what type of visa you applied for?
2. Have you ever had or do you have drug or alcohol addiction? Yes
No
3. Have you ever had any problems with the law or immigration authorities? Yes
No
4. Do you suffer or have you ever suffered from any serious illness? Yes
If yes, please indicate:
5. Do you smoke? Yes
No
If yes, for what reasons?
No
6. Do you have any visible tattoos/ piercing? Yes
No
UAB “ISMIRA” | Taikos pr. 82-1, Klaipeda, LT-93160 Lithuania | Tel./fax +370 46 345621 | www.ismira.lt
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APPLICATION FOR TECHNICAL STAFF EMPLOYMENT
(PLEASE FILL IN USING BLOCK LETTERS)
EDUCATION (LIST ALSO IF NOT COMPLETED)
EDUCATIONAL INSTITUTION – TOWN, COUNTRY
–
–
–
–
–
–
(1)
(2)
(3)
(4)
(5)
(6)
YEARS ATTENDED
FROM - TO
QUALIFICATION (DEGREE) OBTAINED
-
SHIPBOARD EXPERIENCE (START FROM THE MOST RECENT ONE)
FROM
TO
POSITION
SALARY
per month
(1)
NAME OF VESSEL / YEAR
SHIPOWNER / CREWING AGENT /
THEIR ADDRESS
TYPE OF VESSEL / FLAG
TYPE OF ENGINE /
AUTOMATION SYSTEM
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
DWT
BHP
CONTACT PERSON
PHONE NUMBER and/or
E-MAIL
Responsibilities:
(2)
Responsibilities:
(3)
Responsibilities:
(4)
Responsibilities:
(5)
Responsibilities:
LANDBASE WORK EXPERIENCE (START FROM THE MOST RECENT ONE)
FROM
TO
(1)
POSITION
SALARY
COMPANY NAME
ADDRESS
TYPE OF BUSINESS
REASON FOR LEAVING
CONTACT PERSON
PHONE NUMBER / E-MAIL
Responsibilities:
(2)
Responsibilities:
(3)
Responsibilities:
(4)
Responsibilities:
(5)
Responsibilities:
Application date:
Date available:
I certify the above information is true and complete to best of my knowledge, and I authorize you to use this data for the job search
purposes, and make a review of my character and ability. I understand that in carrying out the review, reports may be solicited from
the previous employers, schools, personal and other references.
I also understand that any false statement above is reason for dismissal if engaged.
Signature of applicant:
Please scan signed application, enclose copies of all your certificates and references and return to: [email protected]
UAB “ISMIRA” | Taikos pr. 82-1, Klaipeda, LT-93160 Lithuania | Tel./fax +370 46 345621 | www.ismira.lt
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