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Crewing for seafarers

Application form

Name:
Date of birth: Place of birth:
Nationality: Telephone:
Address:
Marital status: Clothing: Footgear:
Children <16: Height: Weight:
Next of kin:
 
Education:
 
SIC Number: Issued: Expires: Port:
Tourist pas N: Issued: Expires:
Medical certificate Issued: Expires:
 
Rank: English knowledge:
License: Number: Issued:
Endorsement: Number: Issued: Valid:
License: Number: Issued:
Endorsement: Number: Issued: Valid:
 
STCW-95 Courses attended Number Date of issue Date expires
Personal Survival Course
First Aid at Sea
Basic Fire Fighting
Advanced Fire Fighting
Survival Craft
Ship’s Medical Care
Dangerous and Hazardous Cargo
Radar Observation and Plotting
Automatic Radar Plotting Aids (ARPA)
Certificate GMDSS (General)
Certificate GMDSS (Restricted)
 
Vessel Company Type of vessel DWT Type of engine B.H.P. Rank From To
 
Date: Signature:
 
Verification code: Type the numbers you see in the picture below.

 
 
 
 
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phone: (+380) 629 533-933,
fax: (+380) 629 379-350

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