application for seagoing appointment

SEAMAR s.c.
Aleja Jana Pawła II/1
Photograph
(paste here)
81-345 Gdynia
Ph.: +48 58 660 33 40
+48 58 660 33 41
Fax: +48 58 661 52 46
E-mail : [email protected]
www.seamar.pl
APPLICATION FOR SEAGOING APPOINTMENT
1. PERSONAL DETAILS
RANK
ALTERNATIVE RANK (IF ANY)
LAST NAME
FIRST NAME
OTHER NAMES
NATIONALITY
SEX
M
F
BIRTH PLACE
MARITAL STATUS
DATE OF BIRTH
COLOUR OF EYES
MOTHER’S NAME
COLOUR OF HAIR
FATHER’S NAME
HEIGHT (CM)
WEIGHT (KG)
INTERNATIONAL AIRPORT (NEAREST TO HOME TOWN):
2. ADDRESS
STREET
POST CODE
CITY
COUNTRY
TEL. NO.
MOBILE
E-MAIL
FAX
3. NEXT OF KIN
FULL NAME
RELATION
ADDRESS
DATE OF BIRTH
CITY
COUNTRY
TEL. NO.
MOBILE PHONE NO.
FAX NO.
4. BENEFICIARY IN CASE OF DEATH
FULL NAME
RELATION
ADDRESS
CITY
COUNTRY
TEL. NO.
MOBILE PHONE NO.
FAX NO.
5. DETAILS OF CHILDREN (UNDER 18 YEARS OLD)
NAME OF CHILD
SEX
M
F
M
F
M
F
M
F
DATE OF BIRTH
6. TRAVEL DOCUMENTS
DOC./VISA TYPE
DOC./VISA NO.
ISS.DATE
EXP. DATE
ISS. BY (AUTHORITY)
PLACE OF ISSUE
PASSPORT
NAT. ID CARD
NUMBER
SEAMAN BOOK
US C1/D VISA
OTHER VISAS: <type>
7. BANK ACCOUNT INFORMATION (OPTIONAL)
BANK NAME
BRANCH
ADDRESS
CURRENCY
ACCOUNT NO
SWIFT/BIC CODE
ACCOUNT OWNER
8. EDUCATION
SCHOOL NAME
FROM
TO
SCHOOL NAME
FROM
TO
9. CERTIFICATE (S) / LICENCE (S)
LICENCE NAME
NUMBER
ISSUE DATE
ISSUE DATE
EXPIRY DATE
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
NATIONAL:
OTHER:
COURSE NAME
PERSONAL SURVIVAL
BASIC FIRE FIGHTING
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID
MEDICAL FIRST AID
MEDICAL CARE
PERS. SAFETY & SOC. RESP.
PROF. IN SURVIVAL CRAFT
FAST RESCUE BOATS
ECDIS
RADAR OBSERVER
BRIDGE MANAGEMENT
CRISIS MANA ON RO-RO
VESSEL 5
CROWD MANAGEMENT ON RPRO VESSEL 9
GMDSS
ARPA: <type>
HAZMAT
SHIP SECURITY OFFICER
HEALTH CERTIFICATE
YELLOW FEVER VACC
OTHERS
ISSUED BY (AUTHORITY)
ISSUED AT
10. ENGLISH PROFICIENCY
V. GOOD
FLUENT
GOOD
FAIR
POOR
ISSUED ON:
ISSUED BY:
OTHER LANGUEGES PROFICIENCY:
MARLINS TEST
WRITTEN (%):
SPOKEN / LEVEL:
11. SEAFARER’S SAILING RECORD
COMPANY
NAME
VESSEL NAME
VESSEL
TYPE
FLAG
GRT
ENGINE /
DP TYPE1
KW
RANK
SIGN ON
SIGN OF
12. SHORE EXPERIENCE:
13. AVAILABILITY
AVAILABILITY DATE
COMMENTS:
14. REFERENCES
COMPANY NAME
ADDRESS
PHONE NO.
E-MAIL
FAX
CONTACT PERSON
Niniejszym wyrażam zgodę na przetwarzanie moich danych osobowych dla potrzeb działalności pośrednictwa pracy, prowadzonej
przez Seamar SC. z siedzibą w Gdyni, zgodnie z Ustawą z dnia 29.08.1997 r. o Ochronie Danych Osobowych ( Dz. U. Nr 101 z 2002 r., poz. 926
z późniejszymi zmianami), w tym na udostepnianie tych danych podmiotom zagranicznym (potencjalnym pracodawcom). Oświadczam, że
poinformowano mnie, iż mam prawo wglądu i poprawiania danych.
________________________
Imię i Nazwisko
_________________________
Data
http://www.seamar.pl/
1
Engineer Officer to enter Engine type; DP Officer to enter DP equipment type
_________________________
Podpis