Sunteți pe pagina 1din 4

(Passport Photo)

Can be scanned /
sent separately
SEAFARER'S APPLICATION FORM - Page 1 of 4 - PERSONAL DATA
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT-PAGINA 1 DIN 3 DATE
PERSONALE)
PERSONAL INFORMATION ( DATE PERSONALE)
Family Name (Nume)

First Name (s) (Prenume)

Birth Date (Data Naterii)

Birth Place (Locul


naterii)
Religion (Religie)

Nationality (Naionalitate)
Marital Status (Starea
civil)
Height (cm) (naltime)

No. of Children (Nr copii)


Weight (kg) (Greutate n
Kg)

Nearest Airport
(Cel mai apropiat
ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any)
ADRESA (incluzand nr telefon, ara si cod zona, a doua adres sau adresa de contact , dac este cazul )
Street & Nr. (Strad si
Email Address (Adresa
Numr)
Email)
Location (Localitate)
Mobile Phone (Tel mobil)
City (Ora)

Residence Phone (Tel fix)

State, Country (ara)

Fax (Fax)

Postal (ZIP) Code (Cod)

P.O. Box (if any) (CP)

NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary)
RUDA CEA MAI APROPIAT/ MPUTERNICIT ( persona de contact n caz de urgen i beneficiarul
Family Name (Nume)
First Name(s) (Prenume)
Nationality
(Naionalitate)
Street & Nr. (Str. si Nr.)
Location (Localitate)

Relationship (Grad de
rudenie)
Email Address (Adresa
email )
Mobile Phone (Tel mobil)

City (Ora)

Residence Phone (Tel fix)

State, Country (ara)

Fax (Fax)

Postal (ZIP) Code (Cod)

P.O. Box (if any) (C.P)

REMARKS(REMARCI)
Requested Rank(s)
(Funcie)
Prefer Vessel Types
(Tip de nav preferat)
Employment Preference

Availability Date
(Disponibil din)
Minimum Salary(Salariu
minim)

English Language Skills (Limba englez/ Nivel


cunoatere)
Other Foreign Languages (Alte limbi strine)
Professional School / Academy - Name & Period
(From - To) (coala / Nume/ Perioada)
Foreign Crew Experience (specify nationalities)
Experina cu echipaje strine (specificai
naionalitile)
Other Skills
(Alte calitai profesionale)
Further Remarks
(Alte remarci)
I hereby affirm that all the information provided by me in this application is true and correct to the best of
my knowledge.
Prin prezenta confirm c toate informaiile date de ctre mine n aceast formular de aplicare sunt adevrate
i corecte.

Constanta Branch, Romania, 15 Rascoalei 1907 Street, First Floor, Int.05, Open every day 10pm-6pm
T/F (004) 733 183 933 - marinacrewing@gmail.com - Skype - marina.crewing - Facebook - LinkedIn - www.marinacrewing.com

SEAFARER'S APPLICATION FORM - Page 2 of 3 - LIST OF


DOCUMENTS
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT - PAGINA 2 DIN 3
LISTA DOCUMENTELOR)
Family Name
First
Rank
(Nume de
Name(s)
(Funcie)
familie)
(Prenume)
A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES(DOCUMENTE DE CALATORIE/MEDICALE )
Document Name (Desciption)
Document
Country
Issue Place Issue Date
Titlul documentului ( Descriere)
Number Numr ara
Locul
Data
Document
eliberrii
eliberrii
Passport (Pasaport)

Exp. Date
Data
expirrii

Seaman's Book (national) (Carnet Marinar)


Seaman's Book (Norwegian) (Carnet NIS)
(flag state)
Seaman's Book (Liberian) (Carnet Liberia )
(flag state)
Seamans Book (Panama) (Carnet Panama )
(flag state)
Visa - United States (type C1/D) (Viza USA)
Visa - Others (Work/Resid. Permits) (Alte
Vize)
Medical Examination Report (Raport Medical)
Offshore Medical (UKOOA, ENG1)
Vaccination against Yellow Fever (Vaccin
Febra Galben)
Vaccination against Cholera ( Vaccin Holer)
Drug & Alcohol Test (Test Drog/ Alcool)
B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES CERTIFICATE DE COMPETEN
& ENDORSEMENTS , CURSURI
- deck & engine certificates & endor- radio certificates &
- deck, technical & management
sements (officers / ratings)
endorsements
courses (radar/ARPA, ISM, Marpol,
- electrical & reefer certificates
- safety training (surv., fire,
simulators, computer, welding etc.)
- cook & steward certificates
medical)
- Dynamic Positioning Experience
- tanker courses (oil, chem.,
gas)
- passenger vsl, roro, hazmat
courses
Document Name (Desciption)
Document Country
Issue Place
Issue Date Exp. Date
Titlul documentului (Descriere)
Number
ara
Locul
Data
Data
Numar
eliberrii
eliberrii
expirrii
Document
CERTIFICATE of COMPETENCY
ENDORSEMENT
DYNAMIC POSITIONING BASIC
DYNAMIC POSITIONING ADV.
DYNAMIC POSITIONING LICENCE
HUET
BOSIET
RADAR ARPA
GMDSS (GOC)
MARPOL
DANGEROUS CARGO
BASIC/ADVANCED FIRE-FIGHTING
PERSONAL SURVIVAL TECH.
PROFIENCY SURVIVAL CRAFT AND RESCUE
BOATS
PERSONAL SAFETY AND SOCIAL RESP. ON
BOARD
MARITIME ENGLISH
ECDIS
SHIP SECURITY OFFICER
BRG/ENG TEAM MANAGEMENT
Constanta Branch, Romania, 15 Rascoalei 1907 Street, First Floor, Int.05, Open every day 10pm-6pm
T/F (004) 733 183 933 - marinacrewing@gmail.com - Skype - marina.crewing - Facebook - LinkedIn - www.marinacrewing.com

SHIP HANDLING
ELEMENTARY FIRST AID / MEDICAL FIRST AID
MEDICAL CARE
PREVENTION OF MARINE POLLUTION ON
SHIPS:
TRANSPORT AND HANDLING OF
DANGEROUSCARGOES
TANKER FAMILIARIZATION
RO-RO PASSENGER SHIPS

Constanta Branch, Romania, 15 Rascoalei 1907 Street, First Floor, Int.05, Open every day 10pm-6pm
T/F (004) 733 183 933 - marinacrewing@gmail.com - Skype - marina.crewing - Facebook - LinkedIn - www.marinacrewing.com

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).
SEAFARER'S APPLICATION FORM - Page 3 of 3 - SEA SERVICE (LAST 10 YEARS)
Family Name(Nume):
Vessel's Name
(Numele Navei)

Flag
(Pavilion)

GT
(GRT)

First Name(s)
(Prenume):
kW
Ship Type
(Kw)
(Tipul
Navei)

Eng.Maker
(Motor
Principal)

Rank
(Funcie)

S/On Date
(Data
ambarcrii)

Date of
Birth(Data
S/Off Date
Employer (company to
(Data debarcrii) contact for reference)
(Angajator)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10
.
11
.
12
.
13
.
14
.
15
.

Date
Data:

Signature
Semntura:

Constanta Branch, Romania, 15 Rascoalei 1907 Street, First Floor, Int.05, Open every day 10pm-6pm
T/F (004) 733 183 933 - marinacrewing@gmail.com - Skype - marina.crewing - Facebook - LinkedIn - www.marinacrewing.com