APPLICATION FOR EMPLOYMENT
SIEM Ship Management Sp. z o.o.
(as agents only for Owners)
T.Wendy 15 Tel: + 48 58 778 99 20
81 – 341 Gdynia Fax: + 48 58 778 99 21
Poland email:
[email protected] Web:
http://www.siemshipmanagement.com.pl
POSITION applied: Nationality: Date available:
PESEL: e-mail address:
First name: Surname: Date / place of birth: /
Full address
Permanent address:
Present address:
Home telephone : Contact telephones :
Weight (kg): Height (cm): Eye colour: Hair colour:
Passport no: Issued by on: till
USA Visa type Issued at: on: till
Marital status: Number of children under 18 years old: Father’s name:
Next of kin: Name/ address: /
Nearest airport: Shoe size: Boiler suit size:
EDUCATION: GDYNIA MARITIME UNIVERSITY SZCZECIN MARITIME UNIVERSITY OTHER:
Department
Graduated year:
CERTIFICATES OF COMPETENCY :
GRADE NUMBER PLACE DATE EXPIRE
NATIONAL LICENCE:
BAHAMIAN LICENCE:
LIBERIAN LICENCE:
NATIONAL SEAMAN’S BOOK
OTHER SEAMAN’S BOOK:
HEALTH ( Drug and Alcohol tests)
Vaccination: YELLOW FEVER
PERSONAL SURVIVAL TECHN.
PERSONAL SAFETY & SOCIAL RESPONS.
BASIC FIRE FIGHTING
ELEMENTARY FIRST AID
ADVANCED FIRE FIGHTING
MEDICAL FIRST AID
MEDICAL CARE
PROFICIENCY IN SURVIVAL CRAFTS
FAST RESCUE BOATS
GMDSS
ARPA
HAZMAT
ISO F4, Rev.3, 01-04-2019 1/4
ECDIS
RADAR OBSERVER
SSO
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
LANGUAGES ENGLISH : very good good satisfactory poor none
ENGLISH TEST:
OTHER: very good good satisfactory poor none
SEA SERVICE
SHIP’S NAME FLAG OWNER RANK S- ON S- OFF VESSEL Type ME Type GRT / BHP
Medical History
YES NO
Have you ever signed off a ship due to medical reason?
Have you undergone any medical operations in the past?
Have you consulted a doctor during past 12 months for an illness/Accident?
Do you have any health disability problem now?
If answer to any of above is Yes then give further details below or an a separate sheet
REFERENCES
Company name /Person Telephone
ISO F4, Rev.3, 01-04-2019 2/4
NOTE: All STAR Reefers UK LTD Has STRICT Alcohol and Drug Policy, Which means ZERO
TOLERANCE for alcohol and drugs
YES NO
Have you ever been the subject of a court of enquiry or involved in a maritime accident?
Have you ever had a professional license suspended or revoked?
If yes to any of above then please full details below or on separate sheet of paper
BANK ACCOUNT DETAILS
Owner Name: Not required
Owner Address: Not required
Bank Name: Not required
Account No: Not required
SWIFT code: Not required
Office Remarks:
By making an employment application to Siem Ship Management (hereinafter referred to as Controller), its Agencies or appointed Agents I
hereby agree to the following conditions:
1) Siem Ship Management, its Agencies and appointed Agents act in accordance with the provisions of the General Data Protection
Regulation (GDPR) (EU) 2016/679.
2) Data processing of my personal data in the extent mentioned in the application form will be performed only for the purposes of
recruitment process, as well as during the employment process and contracted period of engagement.
3) Personal data provided above will be kept for as long as your consent is not withdrawn. After the withdrawal of your consent, you
will be informed of compliance with your request by the Controller.
4) Please be reminded that despite withdrawal of your consent, Siem Ship Management will store the data in the scope necessary for
fulfilling public law obligations or pursuing legal claims.
5) You have the right to modify the scope of your consent or even withdraw your consent completely at any time – by contacting the
Controller via written notice, e-mail or by phone.
6) Your personal data may be shared with entities, countries and natural persons both inside and outside the EU/EEA area for the
purposes as outlined in pt 2.
7) Should you come to the conclusion that the processing of your personal data by Siem Ship Management is conducted in violation of
the law, you are entitled to file a complaint with the President of the Personal Data Protection Office (address: 2 Stawki Street, 00-193
Warsaw, Poland). The complaint is free of charge.
ISO F4, Rev.3, 01-04-2019 3/4
APPLICANT’S SIGNATURE: .................…………..................... DATE: ………………
ISO F4, Rev.3, 01-04-2019 4/4
