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Seafarer Application Form

This document is an application form for a position with a shipping company. It requests personal details such as name, date of birth, citizenship, and contact information. It also asks for details of the applicant's maritime education, professional certifications and licenses, past employment history working on vessels, medical information, and references. If hired, the form will provide the company with information needed to process employment paperwork and ensure the applicant meets requirements for the role.
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© © All Rights Reserved
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0% found this document useful (0 votes)
195 views5 pages

Seafarer Application Form

This document is an application form for a position with a shipping company. It requests personal details such as name, date of birth, citizenship, and contact information. It also asks for details of the applicant's maritime education, professional certifications and licenses, past employment history working on vessels, medical information, and references. If hired, the form will provide the company with information needed to process employment paperwork and ensure the applicant meets requirements for the role.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 5

APPLICATION FORM

4 0 0 0 6 8
Personal ID Number

Position Applied for Date Available from:


1. Personal Data
Family Name: First Name: Middle Name:
Place of Birth (City and Country):
Date of Birth: Citizenship:
Permanent Address Phone (Home):
Phone (Business/ Mobile)
E-mail:

2. Maritime Education
Name of school Town Country From To Type of degree or diploma

3. Professional Test
English Test Date Name of Test Score

Professional Test Date Score


Name of Test

Professional Interview Date Result

4. Family Details
Civil Status(Single, Married, Separated, Divorced, Widowed) :

Next of Kin (the first emergency contact) Relationship

Address of Residence Phone :

Daughter Son
Family Name
First Name
Date of Birth
City of living
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WWW.AZ-MARINER.AZ
Phone Numbers

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WWW.AZ-MARINER.AZ
5. Identity Documents
Document Country Number Place of Issue Issue Date Expiry Date
Seaman's Book
Travel Passport
Civil Passport

6. Valid Visa
Country or Union Type Valid Until

7. Courses Attended and Certificates Obtained


Dates
Document Number
Issue Expiry
Place
Certificate of Competency
Maltese Endorsement of COC
Oil Tanker Endorsement
Chemical Tanker Endorsement
Gas Tanker Endorsement
Oil Tanker Familiarization Training
Chemical Tanker Familiarization Training
Gas Tanker Familiarization Training
Oil Tankers Specialized Training
Chemical Tanker Specialized Training
Gas Tanker Specialized Training
Basic Trainings
Proficiency in Survival Craft and Rescue Boats
Advanced Fire Fighting
Medical First Aid Training
Medical First Aid Training and Medical Care
GMDSS
GMDSS Endorsement
Radar Observation & Plotting
Automatic Radar Plotting Aids Simulator (ARPA)
Bridge Team Management
Shiphandling & Maneuvering
Ship Security Officer Training Course
Maltese Endorsement of SSO
ISM Code
Safety Officer
ECDISTraining Course
Risk Assessment Course
C.O.W./ I.G.S
Fire Practice on Tankers
Vapour Recovery System
Unmanned Machinery Space
FRAMO Familiarization Course
Cargo Ballast Operations on Oil/Chemical Tankers
Hazardous Materials
Welder
Turner
Risk Management And Incident Investigation
Training of seafarers with designated security
duties in compliance with ISPS Code

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WWW.AZ-MARINER.AZ
8. Physical Data
Height
Weight
Colour of Hair
Colour of Eyes
Boilersuit Size
Shoes Size
9. Medical History Yes No
Have you ever signed off a ship due to medical reasons?
Did you undergo any medical operation in the past?
Have you consulted a doctor during the last 12 months for an illness/accident?
Do you have any health or disability problems now?
If yes, please give full details:

Passed: Valid till:


International Medical Examination
Vaccination Against Yellow Fiver
Vaccination Against Diphtheria

10. References (please give name and address of your current or past employer) Office remarks
Name of Company
Name of person to contact
Address
Phone
Name of Company
Name of person to contact
Address
Phone

11. Bank address for allotments


Beneficiary
Account No.
Name of Bank
Bank Address

12. Knowledge and experience Yes No


OCIMF vetting experience:
ISGOT knowledge:
13. I hereby declare that the above, including Medical History, is true
Place Date Signature

14. For Office use only

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WWW.AZ-MARINER.AZ
15. Seagoing Experience

Vessel’s From To Total


Name of vessel Flag DWT Eng Type HP Manager or Owner Rank
Type d/m/y d/m/y m/d

Total rank sea service: Total type of vessel sea service:


Rank Years Type of vessel Years
OIL TANKER
LPG
DRY CARGO
TANKER ICE
OIL /CHEMICAL TANKER
FERRY
Total Total:

WWW.AZ-MARINER.AZ Page 5 of 5

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