Doc No: PP02 / F01

Application Form and Valid from: 01/01/2011

Record of Personal Information Author: Reliance
and Past Experience Maritime Services
Ltd

Please complete the form by hand or electronically (you can type directly in the fields provided).
Please send the completed application to resume@reliancems.com, or fax it to +40 241 510 409

Present rank: Rank applied for: Date:

Name in full (First, Middle, Last): Nationality: Expected wages:
ROMANIAN
Date of birth: Age: Married /Single/Divorced Photo

Place of birth: Next of kin

Permanent / Contact address: Name:
Relationship:
Address:

Home phone number: Mobile number: Fax number: Email address:

+40 +40
Nearest airport: OTP - Bucharest Height(cm): Weight(kg):
Medical and visas
If accepted, date available for service: U.S. Visa: Type: Valid until:

CFR Medical Certificate expiry date: Other Visa: Type: Valid until:

Yellow fever vaccination expiry date: Other Visa: Type: Valid until:

Professional Qualifications
Licenses Grade of license Number Date issued Place issued / Expiry Date
Revalidated
National
Romanian
Other

Other

Other

Seaman’s book Place & date Expiry date Passport Place & date Expiry date
number / issued nationality / issued
Nationality Number

Referees: 1) 2)
company,contact
person, phone no
 Doc No: PP02 / F01
Application Form and Valid from: 01/01/2011
Record of Personal Information Author: Reliance
and Past Experience Maritime Services
Ltd

Other Endorsements / Professional qualifications / Certificates held

Endorsement / Course / Certificate Number / Place held Date held Expiry date
Certificate of Competency (COC)
Medical Certificate
STCW Endorsement
Oil Tanker
Chemical Tanker
LPG / LNG Tanker
GMDSS (GOC)
Certificate of Capacity
     

Sea Service Experience

Deck Engine
Vessel Type of Company Period
Flag Trading & Type & Rank
name vessel name From – To
DWT BHP
Last

2nd
Last

3rd
Last

4th
Last

5th
Last

6th
Last

7th
Last

8th
Last

9th
Last

Other experiences (New buildings / Dry docks / Repair yards etc.

 Doc No: PP02 / F01
Application Form and Valid from: 01/01/2011
Record of Personal Information Author: Reliance
and Past Experience Maritime
Services Ltd

Marine Course Attended No# / Institution Date of issue Expiry date

Basic Fire Fighting
Advanced Fire Fighting
Personal survival techniques
Medical First Aid
Advanced Medical Care
Proficiency in Survival Crafts
Tankers familiarization
Specialized Tanker Training (Oil)
Specialized Tanker Training (Chemical)
Specialized Tanker Training (Gas)
Prevention of pollution
GMDSS
ARPA
Electronic Chart Display & Information
Systems
Ship handling Simulator
Engine room simulator
Bridge Team Management
Engine Team Management
Maritime English
Crew Resource Management Course
Personal Safety & Social Responsibilities
Dangerous Goods Handling
Ship Safety Officer
Ship Security Officer
Behavioral Safety Awareness
Safety Awareness / Accident Prevention
Fast Rescue Craft
Standby Vessel Advanced Medical Aid
Standby Vessel Command & Control
Standby Vessel - Initial Training for
Shipboard operations
Helicopter Underwater Escape Training
Helideck Assistant
 Doc No: PP02 / F01
Application Form and Valid from: 01/01/2011
Record of Personal Information Author: Reliance
and Past Experience Maritime
Services Ltd

Helicopter Landing Officer

Offshore Emergency Helideck Team
Member
Dynamic Positioning (Basic)
Dynamic Positioning (Advanced)
Any other Relevant Training:
     
     
     
     
     
     
     
     

I certify that the above information are true and correct. I fully understand and agree that any false
declaration herein above shall result in instant dismissal without any responsibility or liability
whatsoever on the part of the company.

Date: Signature:

Reliance Maritime Services Ltd has been registered to the A.N.S.P.D.C.P. (National Survey Authority of
Personal Data Processing) with the evidence number '18456' - to protect individuals from the point of view
of personal data processing and with the freedom of using the data on each document through which
personal data are collected, stocked and revealed only in recruitment and employment purposes.