APPLICATION FOR EMPLOYMENT

Personal Data
First Name Father’s Name Last Name / Surname
AFFIX HERE YOUR
Position Applied For Date of Birth (dd/mm/yy) Place of Birth RECENT PASSPORT
SIZE PHOTOGRAPH

Nationality OIB □ Female □ Male Available date

Home Address / City: Personal Documents Issued on Valid until

Passport (Country / Number)
Croatia
Seaman’s book
Croatia
Mob. / Home number: USA C1/D visa

E-Mail: Medical Fitness Certificate

National Certificates of Competence Next of kin

Grade Issued Expires Name and Surname:
Phone:
Relationship:

Other valid certificates and training attended

Basic Safety Training Advanced Fire Fighting Medical First Aid Medical Care ECDIS (Generic, IMO 1.27)
Ship Security Officer Bridge Team Management Dangerous Cargo Handling
ERRM ECDIS (Type Specific)

Education History (Mandatory): Name of Institution / Level / Graduate Date:

Please answer the following questions:

 Did you suffer, or presently suffer from, any disease likely to render you unfit for services at
sea or likely to endanger the health of other persons on board?
If yes, please provide details _______________________________________________ YES NO
______________________________________________________________________

 Did you suffer any accident, which rendered you temporary and/or partially disabled? YES NO
 Did you ever undergo psychiatric treatment? YES NO
 Are you addicted to alcohol or drugs of any kind? YES NO
I hereby declare that the above facts and information are true and accurate. I understand that this data will be stored in the Managers’ database for the purposes of my
current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organization .

Place___________________________ Date____ Signature______________________________

For Office Use

Initial assessment of applicant for further recruitment
Comments

Responsible person
Name / Signature ____________ ___________________________________ Date _________

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Jadroplov d.d. - Obala kneza Branimira 16, 21000 Split, E-mail: personnel@jadroplov.com
 APPLICATION FOR EMPLOYMENT - SEA SERVICE
Sea Experience : (Last 5 years; Start the listing below with the most recent experience)
Date From Date To Reason for
Company Flag Vessel Name Type (1) GRT DWT Main Engine Rank
(dd/mm/yy) (dd/mm/yy) S/off (2)

(1)
*Please use only following abbreviations for the vessel type: Use only the following abbreviations for vsl types:
(2)
Reason of Sing Off, e.g. “EOC – End of Contract”,
GCD General Cargo MLP Multi-Purpose B/C Bulk Carrier CON Container O/O Ore Oil OBO Ore/Bulk/Oil
“MED – Medical Ground”, “OWN – Own
TNC Tanker Crude TNP Tanker Product FSO / FPSO TNV VLCC/ULCC
LPG request”
Please
CHM Chemical Tank provide
PAS details
Passenger Ship ofR/O
two recent employers
Ro/Ro who DRG
LSH Lash we may contact forOSV
Dredger references
Offshore Supply
Name of Company
LNG
SRV
NameSurvey vessel
of person LOG Log/Timber
to contact NVL Naval Ship SSHL Semi-Submergible Heavy Lift
MOB Mobile Offshore Unit
Address

Telephone/E-Mail

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Jadroplov d.d. - Obala kneza Branimira 16, 21000 Split, E-mail: personnel@jadroplov.com