OPN101 REV.
9/10-01-11
Date:
Citizen ID:
A. SEAMAN’S APPLICATION FORM
Rank (License held) Position Applying for
Surname First Name Middle Name
Date of Birth dd/mm/yy Place of Nationality TURKISH
Birth
Address
CellPhone No. Landline Email Address:
No.
Father’s Name Mother’s
Name
Highest Educational Attainment School
Marital Status YES NO Skype : Yoksa bir adres temin ediniz..
Name of Beneficiary Yakınınızın ismini giriniz. Relation Yakınlık derecesini giriniz.
Address Yakınınızın adresini giriniz. Contacts Yakın. telefonunu giriniz.
Seaman’s Book No. 9 haneli Placed Issued Date Issued dd/mm/yy Date Valid dd/mm/yy
olmalıdır.
Passport no. 9 haneli Placed Issued Date Issued dd/mm/yy Date Valid dd/mm/yy
olmalıdır.
USA VISA Type: Date dd/mm/yy Date Valid : dd/mm/yy
Issued :
Schengen VISA Type: Date dd/mm/yy Date Valid : dd/mm/yy
Issued :
Other Countries VISA Type: Date dd/mm/yy Date Valid : dd/mm/yy
Issued :
English Ability Very Good Good Fair Poor
Height Weight (kg) Date of Military Service:
(cm)
B. DOCUMENTATION
Documents Placed Issued Date Issued Date Expire
Personnel Survival Techniques Training Certificates dd/mm/yy dd/mm/yy
Elementary First Aid Training Certificate dd/mm/yy dd/mm/yy
Fire Prevention and Fire Fighting Training Certificate dd/mm/yy dd/mm/yy
Personnel safety and Social Responsibility Training Certificate dd/mm/yy dd/mm/yy
Proficiency İn Survival Craft and Rescue Boats (other than fast rescue boats) dd/mm/yy dd/mm/yy
Radar Observation and Plotting Training Certificates dd/mm/yy
Plotting Aids (ARPA) Training Certificate dd/mm/yy
ECDIS dd/mm/yy
BRM dd/mm/yy
ERM dd/mm/yy
Medical First Aid Training Certificate dd/mm/yy
Medical Care Training Certificate dd/mm/yy
Advanced Fire Fighting Training Certificate dd/mm/yy dd/mm/yy
Ship Security Officer Certificate dd/mm/yy dd/mm/yy
Designated Security Duties Certificate0 dd/mm/yy
Security Awareness Certificate dd/mm/yy
Security –Related Familirazition Certificate dd/mm/yy
Oil Tanker Familiariztion Certificate dd/mm/yy dd/mm/yy
Specialized Training Programme on Oil Tanker Oper. Cert. dd/mm/yy dd/mm/yy
Chemical Tanker Familiariztion Certificate dd/mm/yy dd/mm/yy
Specialized Training Prog. on chemical Tanker Oper. Cert. dd/mm/yy dd/mm/yy
Liquefid Gas Tanker Familiariztion Certificate dd/mm/yy dd/mm/yy
Specialized Training Prog. on Liquefid Gas Tanker Oper. Cert. dd/mm/yy dd/mm/yy
CONTACT DETAILS Phone: +902168016484, +902167473474
Address: Bagdat Caddesi No:244/5 Ergun Apt. E-mail:
[email protected] Caddebostan, Kadikoy, Istanbul, Turkey Web: www.omikroncrew.com
Documents Placed Issued Date Issued Date Expire
COC (CERTIFICATE OF COMPETENCE) – Number: 6 haneli olmalıdır. dd/mm/yy dd/mm/yy
GMDSS (GOC-ROC-REO )( mark) - Number: 6 haneli olmalıdır. dd/mm/yy dd/mm/yy
Vaccination Certificate dd/mm/yy
Drug & Alcohol Test dd/mm/yy dd/mm/yy
Pre-employment Medical Examination dd/mm/yy dd/mm/yy
Fast Rescue Boat dd/mm/yy dd/mm/yy
Training for Passenger Vessels dd/mm/yy dd/mm/yy
Medical Examination Certificate dd/mm/yy dd/mm/yy
Course Attended
TYPE OF SPECIFIC ECDIS ( FURUNO,JRC,TRANSAS ETC.) : Daha önce çalışmış olduğunuz ve sertifikası bulunan ECDIS tiplerini yazınız.
B. as
C. ENDORSEMENTS
Flag Rank Number Date Issue Date of Expire
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
D. PREVIOUS SEA SERVICE FOR TANKERS
Rank Master C/O 2/O 3/O C/E 2/E 3/E 4/E
Years
With Operator
Years In Rank
Type Of Tanker
All Types of Tanker
PARAGRAPH D WILL BE COMPLETED BY THE CREW OPERATOR BEFORE SENDING FOR APPROVAL TO SPECIFIC TANKER PRINCIPALS, THE YEARS WILL BE THE
AGGREGATE OF BOTH PAIRS OF OFFICERS INDICATED (MASTER & C/O, C/E & 2/E, ETC
E. PREVIOUS SEA SERVICE (Start with the latest)
Ex- Crew New Crew
Company Vessel Engine DWT Vessel Ran Date Date Cause of
Name & Type & Type & k Embarked Disembarked Discharge
Flag BHP Year Built (dd/mm/yy) (dd/mm/yy)
. dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
dd/mm/yy dd/mm/yy
Remarks: EN SON HİZMET EN ÜSTTE OLMALIDIR. LÜTFEN BÜTÜN DENİZ HİZMETLERİNİZİ SIRAYLA BELİRTİNİZ.SUTUN
EKLEYEBİLİRSİNİZ.
F. PREVIOUS EMPLOYER
Employer’s Name
Date Appointed Position
Allowance, if any
Reason for leaving:
CONTACT DETAILS Phone: +902168016484, +902167473474
Address: Bagdat Caddesi No:244/5 Ergun Apt. E-mail:
[email protected] Caddebostan, Kadikoy, Istanbul, Turkey Web: www.omikroncrew.com
Does your employer know your
leaving?
When would you able to enter our company? HAZIR OLDUGUNUZ TARIHI VE BEKLEYEBİLECEĞİNİZ TARİHİ YAZINIZ.
Any previous ILLNESS? If YES, State the illness:
SAĞLIK DURUMU İLE AYRILDIYSANIZ, NEDENİNİ LÜTFEN PAYLAŞINIZ.
CHARACTER REFERENCE FROM PREVIOUS COMPANY:
Two persons other that relatives to whom we can refer regarding yourself.
Name: Name:
Company Company
Address Address
Tel/Cell No. Tel/Cell no.
Period known: Period Known:
Date Signature
CONTACT DETAILS Phone: +902168016484, +902167473474
Address: Bagdat Caddesi No:244/5 Ergun Apt. E-mail:
[email protected] Caddebostan, Kadikoy, Istanbul, Turkey Web: www.omikroncrew.com
