APPLICATION FOR TECHNICAL STAFF EMPLOYMENT
(PLEASE FILL IN USING BLOCK LETTERS)
E-mail to: [email protected]
Salary desired
Positions applied for
PHOTO
(USD per month)
SURNAME
(family name)
NAME
Date of birth
Citizenship
(Nationality)
Height (cm)
Weight (kg)
Home Address
Place of birth
Marital status
Number of children under 18 years
(incl. postal code)
Contact Phones
Mobile:
E-mail address
Next of kin name
Next of kin’s address
Native
Language:
Home:
SKYPE address
Relation to you
Phone no:
English
fluency:
DOCUMENT
Travel Passport
Seaman’s Book
National Passport (ukr)
Valid U.S. VISA C1D
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 UNTIL
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 till
CERTIFICATE
Place of issue
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
Security Awareness (A-VI/6-1, course 3.27)
Security Awareness (A-VI/6-1, course 3.26) (duties)
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? Yes
2. Have you ever had or do you have drug or alcohol addiction? Yes
5. Do you smoke? Yes
If yes, please indicate:
No
3. Have you ever had any problems with the law or immigration authorities? Yes
4. Do you suffer or have you ever suffered from any serious illness? Yes
No
No
No
If yes, for what reasons?
If yes, please indicate:
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
- Page 1
APPLICATION FOR TECHNICAL STAFF EMPLOYMENT
(PLEASE FILL IN USING BLOCK LETTERS)
UAB “ISMIRA” | Taikos pr. 82-1, Klaipeda, LT-93160 Lithuania | Tel./fax +370 46 345621 | www.ismira.lt
- Page 2
APPLICATION FOR TECHNICAL STAFF EMPLOYMENT
(PLEASE FILL IN USING BLOCK LETTERS)
EDUCATION (LIST ALSO
EDUCATIONAL INSTITUTION – TOWN, COUNTRY
IF NOT COMPLETED)
DAY/MONTH/YEAR ATTENDED FROM TO
(1) –
QUALIFICATION (DEGREE)
OBTAINED
-
(2) –
SHIPBOARD EXPERIENCE (START FROM THE MOST RECENT ONE)
FROM
TO
POSITION
SALARY
per month
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:
Responsibilities:
Responsibilities:
Responsibilities:
Responsibilities:
Responsibilities:
LANDBASE WORK EXPERIENCE (START FROM
FROM
TO
POSITION
SALARY
COMPANY NAME
ADDRESS
THE MOST RECENT ONE)
TYPE OF BUSINESS
CONTACT PERSON
REASON FOR LEAVING
PHONE NUMBER / E-MAIL
Responsibilities:
Responsibilities:
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.
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)
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
- Page 4