INTERNATIONAL CREWING AGENTS
BRANCH OFFICE IN UKRAINE
88/1 Panteleymonovskaya str., office 302, 3rd floor, Odessa, Ukraine
Tel.: +380487851820; Fax: +3807851821
E-mail:
[email protected], www.acomarin.com.ua
F1.1 APPLICATION FOR EMPLOYMENT
Please type or use block letters. Please complete in the English Language.
1. POSITION APPLIED FOR
2. FAMILY NAME (as in Seaman’s Book)
3. FIRST NAME (as in Seaman’s Book)
4. DATE OF BIRTH
(DD.MM.YYYY) 5. PLACE OF BIRTH
6. COMPLETE ADDRESS (Only in English). Please indicate an ALTERNATIVE TELEPHONE NUMBER or a
PHOTO 3 X 4 NUMBER OF YOUR NEIGHBOURS if the direct line is not available.
7.MARITAL STATUS e-mail
(Please mark which is relevant).
Married Single Divorced Widow/Widower 8.CITIZENSHIP
9. NEXT OF KIN (Please advise compulsory the following information).
d) Place of Residence (Please state "THE SAME" if coincides with your permanent address
a) Relationship
stated above)
b) Family Name
c) First Name
e-mail
10. OTHER PERSONAL DATA
a) Height b) Weight c) Boots Size d) Overall Size
e) Color of Eyes f) Color of Hair
11. MARITIME EDUCATION
Period of Studies
Educational institution Specialty Place From To
Courses School College Academy
12. CERTIFICATES OF COMPETENCY
Grade / Class/STCW Code Number Date of Issue Date of Expire Country
(DD.MM.YY) (DD.MM.YY)
Certificate of Competence:
Endorsement:
Basic Safety Course (VI/1)
Advanced Fire Fighting (VI/3)
Medical First Aid (VI/4-1) Medical Care (VI/4-2)
Survival Craft and Rescue boats (VI/2-1)
Proficiency in Fast Rescue Boats (VI/2-2)
Tankerman Oil Familiarization Advanced
Tankerman Chemical Familiarization Advanced
Tankerman Gas Familiarization Advanced
ARPA Operational Management
GMDSS General Operator
Bridge Engine Resource Management
Maneuvering & Ship Handling
Welder Electro Gas TIG
ECDIS
Ship Security Officer Designated Security Duties
Please turn over and complete the reverse side.
13. PASPORTS AND VISAS (Please OBLIGATORY advise the complete details of your passports) 14. MEDICAL CERTIFICATE AND VACCINATIONS
Type Country Serial Number Date of Issue Date of Expire Date of Issue Date of Expire
(DD.MM.YY) (DD.MM.YY) (DD.MM.YY) (DD.MM.YY)
National Passport Medical Certificate
Tourist / Travel Passport Drug & Alco Test Certificate
Seaman's Book / Seaman’s Passport Yellow Fever Vaccination
Other Seaman’s Book 15. TESTS
Other Seaman’s Book MARLINS test result % date
US Visa C1/D CES 4.1 test result % date
Schengen Visa
16. PREVIOUS SEA SERVICE (Please submit the complete information about your service at sea during last five years)
Owners or Managers Vessel's name Type of vessel Flag GRT Kwt Type of Engine Rank Sign-on Sign-off
(DD.MM.YY) (DD.MM.YY)
DECLARATION: I do hereby declare that all the above statements are complete and correct to the best of my knowledge. I do understand that this application form contains information vital for my further employment, however, its presenting gives me no
guarantee for such unless proper requirement available. I do also understand that the below assessments of my qualifications and knowledge will affect my ability to be employed via LAPA Ltd.
DATE OF APPLICATION: SIGNATURE:
WHILE SUBMITTING YOUR APPLICATION
Please attach: the originals of all the documents you have indicated above, all of your passports, your medical book, and your vaccination book.
Have your tests passed.
Your application will not be accepted unless it complies with all the above requirements.
THANK YOU! DO NOT WRITE ON THE SPACE BELOW!
Test in English Authorized Professional Competence Test Authorized
Score: Score:
passed (date): signature: passed (date): signature:
This application form is property of LAPA Limited Company. No copies of this form will be accepted by the company. All rights for duplication and distribution are reserved. "LAPA" is the registered trademark of LAPA Limited Company. Form F1.1.,
research by VMO 2007.
