ANGLO-EASTERN UKRAINE

84, BALKOVSKAYA STREET, OFFICE 401, ODESSA 65005, UKRAINE

TEL / FAX : + 380 48 734 0787 / 86 E-MAIL: APPLICATION.UA@ANGLOEASTERNGROUP.COM

EMPLOYMENT APPLICATION FORM

FORMAT OF ALL THE DATES MUST BE FOLLOWING: DD.MM.YYYY

Family
Name       Name       Middle Name      
Position Second choice Nationality/
applied for*: ..... (if any): ..... Citizenship      

Place of Birth       Date of Birth      

App. House, Street

          
Home
Village City (Regional Center) Postal Code Country
Address
                       

Home Phone       E-mail      

Mobile Phones       Skype      
Married Children Year of birth Name
under Number
Single            
Marital Status 21
Divorce            
years   
d
Widower old            

Next of kin       Relation ...

App. House, Street City Country
Contact
Address      
                      details

Issued
Seaman’s Book & Passports № Valid until
Place Date
Seaman’s Book                        
Travel Passport                        
Civil Passport                  

National COC - Certificate of Competency - Issued

№ Valid until
with Endorsement and Flag Endorsements if any Place Date
National COC .....                  
Endorsement .....                        
      .....                        
      .....                        
      .....                        

Fluently Good Fair Basic Marlins, % CES 4.1 % SETS, %      

English Ability
           

Education (Maritime or other Graduating

           
Academy, University, or College) Year

Distinctive marks (if any): Height(cm): Weight (kg): Robe size Shoes size
                     

Last monthly wage US$       Desirable monthly wage US$       Date of readiness      

Brief information about 3 previous Employers

Please ensure that the full name and address of your last 3 employers are entered in appropriate section below

Company Person in charge Contact phone number

                 
                 
                 

DOCUMENTATION
Issued
Documents № Valid until
Place Date

AESM GROUP: HTTP://WWW.ANGLOEASTERNGROUP.COM AE-UKRAINE: HTTP://ANGLOEASTERNUKRAINE.COM/

 ANGLO-EASTERN UKRAINE
GMDSS CERTIFICATE                        
GMDSS ENDORSEMENT                        
BASIC SAFETY TRAINING                        
PROFICIENCY IN SURVIVAL CRAFTS & RESCUE BOATS                        
FAST RESCUE BOATS                        
MEDICAL FIRST AID TRAINING                        
MEDICAL CARE                        
ADVANCED FIRE FIGHTING                        
HAZARDOUS MATERIALS                        
SHIP SECURITY OFFICER                        
DESIGNATED SECURITY DUTIES OF SHIPBOARD
PERSONNEL
                       
SHIP SECURITY AWARENESS                        
SHIP SECURITY PLAN                        
SHIP'S SAFETY OFFICER                        
ARPA                        
BREATHING APPARATUS                        
EL. AND ELECTRONICAL ENGINEERING                        
OIL TANKER ADVANCED                        
OIL TANKER FAMILIARIZATION                        
GAS CARRIER ADVANCED                        
GAS CARRIER FAMILIARIZATION                        
TANKER FAMILIARIZATION                        
TANKER CARRIER ADVANCED                        
CHEMICAL TANKER ADVANCED                        
CHEMICAL TANKER FAMILIARIZATION                        
PASSENGER SHIPS                        
RO-RO PASSENGER SHIPS V/2                        
MOORING & UNMOORING                        
STEERING COURSE                        
BRIDGE TEAM MANAGEMENT                        
ECDIS                        
                             
                             
                             
                             
                             
                             
SHENGEN MULTI VISA                        
USA ENTRY VISA                        

MEDICAL EXAMINATIONS
Documents Clinic Name / Place Issue Date Expire Date
ILO MEDICALS                  
VACCINATION YELLOW FEVER                  
VACCINATION CHOLERA                  
VACCINATION TYPHOID                  
VACCINATION TETANUS                  
VACCINATION HEPATITIS B                  
DRUG AND ALCOHOL TEST                  

AESM GROUP: HTTP://WWW.ANGLOEASTERNGROUP.COM AE-UKRAINE: HTTP://ANGLOEASTERNUKRAINE.COM/

 ANGLO-EASTERN UKRAINE

Last 7 years of SEA SERVICE (for Seniors Officers – last 10 years)

Signed
Ship’s name Ship’s type * Engine type*** Owners or Managers of the vessel
On****
# Rank
Signed
Flag DWT / TEU** Modification *** BHP *** Employed via Crewing Agency
Off****
      ... ...            
1 .....
                                   
      ... ...            
2 .....
                                   
      ... ...            
3 .....
                                   
      ... ...            
4 .....
                                   
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5 .....
                                   
      ... ...            
6 .....
                                   
      ... ...            
7 .....
                                   
      ... ...            
8 .....
                                   
      ... ...            
9 .....
                                   
      ... ...            
10 .....
                                   
      ... ...            
11 .....
                                   
      ... ...            
12 .....
                                   
      ... ...            
13 .....
                                   
      ... ...            
14 .....
                                   
      ... ...            
15 .....
                                   
* See decoding of abbreviation below ** For container vessels only ***Required for Engineers only
**** Format of all the dates must be following: DD.MM.YYYY

Date       Signature

I hereby confirm that above information is true and correct to the best of my knowledge. I understand that this information will be held in the computer database due to my real or possible employment.
Signing it, I willfully give my permission to collect and process my personal information and to use it in all and any legal way. I give my permission for my personal information to be provided to the
possible employers and any other persons, if such need arises from my employment. Besides, I permit the Anglo-Easter Ukraine ltd. employees to request personal information (data) about me from
my former employers.
Цим заявляю, що усі вказані мною вище дані є вірними, дійсними та правдивими. Я розумію, що ці відомості будуть зберігатися в електронній базі даних в зв’язку з моїм реальним чи
можливим працевлаштуванням. Підписуючи, це я добровільно надаю дозвіл на збір та обробку моїх персональних даних та на використання їх будь яким, не забороненим законом
шляхом. Я дозволяю передавати мої персональні дані можливим працедавцям, та будь яким іншим особам, якщо така передача обумовлена необхідністю, пов’язаною з моїм
працевлаштуванням. Також, дозволяю співробітниками ТОВ «Англо - Істерн Україна» запитувати персональну інформацію (данні) про мене, від моїх попередніх працедавців.
AE-UA Application Form SP V.2.3 dated 27.12.2013

AESM GROUP: HTTP://WWW.ANGLOEASTERNGROUP.COM AE-UKRAINE: HTTP://ANGLOEASTERNUKRAINE.COM/