FORMS MANUAL Document Number : CMO/03

SECTION 3 - APPLICATION Section Revision Number : 02

Page Number : 1 of 3

Application for Employment

Personal Data
First Name Middle Name Last Name / Surname
Mindia Basiladze AFFIX HERE YOUR
RECENT PASSPORT
Nationality Date Of Birth (dd/mm/yy) Place of Birth SIZE
Georgian 25 March 1981 Batumi PHOTOGRAPH
Position Applied For Available date
3rd / Officer
□ Female x Male

Home Address Personal Documents Issued on Valid until

Georgia / Batumi Passport (Country / Number)
Alexandre Pushkini 39 / 24 Georgia / 61001022133
Seaman’s book
Georgia / GE000797
USA C1/D visa

Telephone Schengen Visa

+995 596 090900
E-Mail Medical Fitness Certificate
[email protected]

National Certificates of Competence Tanker Endorsements

country_______________________ Management level □ Operation level □
Grade Issued Expires Oil Chemical Gas

Valid Flag State Liberia □, Panama x, Malta □, Marshall Islands x, UK □, Singapore □, Norway (DIS) □,
Endorsements Other (list flags)
GMDSS Flag State GMDSS Endorsements (list)
General / Restricted

Other valid certificates and training attended

□ Basic Safety Training □ Advanced Fighting □ Medical First Aid □ Medical Care □ ECDIS (generic)
□ ECDIS (type specific) □ Bridge Team Management □ Ship Handling □ Liquid Cargo Handling □ ER Management
Other (specify)

Please answer the following questions:

 Did you suffer, or presently suffer from any disease likely to render you unfit for services at sea or
likely to endanger the health of other persons on board? □YES
If yes, please provide details ________________________________________________________
________________________________________________________________________________ xNO
 Did you suffer any accident, which rendered you temporary and/or partially disabled?
□YES
xNO
 Did you ever undergo psychiatric treatment
□YES
xNO
 Are you addicted to alcohol or drugs of any kind?
□YES
xNO
I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I
may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers
(together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a
later date, including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts
applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers’ database for the purposes of my current or future
employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organization.

Place___________________________ Date _________________________ Signature ______________________________

For Office Use

Initial assessment of applicant for further recruitment
Comments ___________________________________________________________________________________________
FORMS MANUAL Document Number : CMO/03
SECTION 3 - APPLICATION Section Revision Number : 02
Page Number : 2 of 3
____________________________________________________________________________________________________
____________________________________________________________________________________________________

MSO responsible person

Name / Signature _______________________________________________ Date ________________________________
FORMS MANUAL Document Number : CMO/03
SECTION 3 - APPLICATION Section Revision Number : 02
Page Number : 3 of 3
Sea Experience : (Last 10 years; Start the listing below with the most recent experience)
Date From Date To Reason for
Company Flag Vessel Name Type (1) GRT DWT Main Engine (2) BHP Rank
(dd/mm/yy) (dd/mm/yy) Sign off (3)

ANTARES OIL/CHEMICAL
PANAMA M/T ANAMARIA 5031 6487 T 4039 3RD/OFFICER 21 NOV 2015 16 JULY 2016 END OFF
SHIPMANAGMENT TANKER CONTRACT

COLUMBIA MARSHALL, OIL/CHEMICAL END OFF

M/T CAPE BEIRA 25400 40046 T 11640 3RD/OFFICER 22 OCT 2014 9 JULY 2015
SHIPMANAGMENT LTD ISLANDS TANKER CONTRACT

COLUMBIA MARSHALL, OIL/CHEMICAL JUNIOR END OFF

M/T CAPE BRADLEY 25108 35159 T
SHIPMANAGMENT LTD ISLANDS TANKER OFFICER CONTRACT

COLUMBIA MARSHALL, OIL/CHEMICAL ABLE END OFF

M/T CAPE BRADLEY 25108 35159 T
SHIPMANAGMENT LTD ISLANDS TANKER SEAMAN CONTRACT

(1)
*Please use only following abbreviations for the vessel type: Use only the following abbreviations for vsl types:
(2)
Engineers to give make/model of engines, e.g. “MAN 14V52/55A”
GCD General Cargo MLP Multi-Purpose B/C Bulk Carrier CON Container O/O Ore Oil OBO Ore/Bulk/Oil or “SULZER 5RTA58”
TNC Tanker Crude TNP Tanker Product FSO / FPSO TNV VLCC/ULCC LPG (3)
CHM Chemical Tank PAS Passenger Ship R/O Ro/Ro LSH Lash DRG DredgerOSV Offshore Supply LNG Reason of Sing Off, e.g. “EOC – End of Contract”,
SRV Survey vessel LOG Log/Timber NVL Naval Ship SSHL Semi-Submergible Heavy Lift MOB Mobile Offshore Unit “MED – Medical Ground”, “OWN – Own request”
Please provide details of two recent employers who we may contact for references
Name of Company
Name of person to contact
Address

Telephone/E-Mail