Personal Information: (Passport Photo) Can Be Scanned / Sent Separately [PDF]

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(Passport Photo) Can be scanned / sent separately

43rd Primaverii street, 900635, Constanta, Romania Tel: +40 721 938432 +40 241 584483 Web: www.oilgasrecruitment.ro Crew Department Email: [email protected]

SEAFARER'S APPLICATION FORM - Page 1 of 3 - PERSONAL DATA

PERSONAL INFORMATION Family Name Birth Date Nationality Marital Status Height (cm) Nearest Airport

First Name (s) Birth Place Religion No. of Children Weight (kg)

ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any) Street & Nr. Location City State, Country Postal (ZIP) Code

Email Address Mobile Phone Residence Phone Fax P.O. Box (if any)

NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary) Family Name Nationality Street & Nr. Location City State, Country

First Name(s) Relationship Email Address Mobile Phone Residence Phone Fax

Postal (ZIP) Code

P.O. Box (if any)

REMARKS Requested Rank(s) Availability Date Prefer Vessel Types Minimum Salary Employment Preference All English Language Skills Spoken: average/good/fluent - Written: average/good/fluent Other Foreign Languages Professional School / Academy - Name & Period (From - To) Foreign Crew Experience (specify nationalities) Other Skills Further Remarks I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge.

SEAFARER'S APPLICATION FORM - Page 2 of 3 - LIST OF DOCUMENTS Family First Name Name(s) A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES Document Name (Desciption) Document Number Country Passport Seaman's Book (national) Seaman's Book (flag state) Seaman's Book (flag state) Visa - United States (type C1/D) Visa - Others (Work/Resid. Permits) Medical Examination Report Offshore Medical (UKOOA, ENG1) Vaccination against Yellow Fever Vaccination against Cholera

Rank

Issue Place Issue Date Exp. Date

B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES - deck & engine certificates & endor- - radio certificates & endorsements - deck, technical & management sements (officers / ratings) - safety training (surv., fire, courses (radar/ARPA, ISM, Marpol, - electrical & reefer certificates medical) simulators, computer, welding etc.) - cook & steward certificates - tanker courses (oil, chem., gas) - Dynamic Positioning Experience - passenger vsl, roro, hazmat courses Document Name (Desciption) Document Number Country Issue Place Issue Date Exp. Date CERTIFICATE of COMPETENCY ENDORSEMENT DYNAMIC POSITIONING BASIC DYNAMIC POSITIONING ADV. UK DYNAMIC POSITIONING LICENCE LONDON HUET BOSIET RADAR ARPA GMDSS (GOC) MARPOL DANGEROUS CARGO ADVANCED FIRE-FIGHTING PERSONAL SURVIVAL TECH. PROFIENCY SURVIVAL CRAFT PERSONAL SAFETY MARITIME ENGLISH ECDIS SHIP SECURITY OFFICER BRIDGE TEAM MANAGEMENT SHIP HANDLING MEDICAL FIRST AID MEDICAL CARE

OIL & GAS RECRUITMENT SEAFARER'S APPLICATION FORM - Page 3 of 3 - SEA SERVICE (LAST 10 YEARS) Please indicate your sea service in the last 10 years as exactly as possible - required are the actual sign-on and sign-off dates according to the service certificates resp. seaman's book entries. To speed up processing kindly indicate phone and/or fax numbers of your previous employers. Ship sizes are to be indicated in gross tons, total engine output in kilo Watt (1 kW = 1.34 bhp) to go along with STCW limitations. Please attach evidence for the listed sea service (copies of seaman's book entries, service certificates etc.). The information provided may be passed on to our clients and to flag state administrations to allow for verification of rank experience. Please use the European date format (DD.MM.YY). Family Name: Vessel's Name

First Name(s): Flag

GT

Date: Oil & Gas Recruitment Ltd. 18th Brizei str. FD3, Constanta, Romania www.oilgasrecruitment.ro, [email protected]

kW Ship Type

Signature:

Date of Birth: Eng.Make

Rank

S/On Date S/Off Date Employer (company to contact for reference)