Seafarer's Application Form

Position applied for:
Surname:
Name:
Date and place of birth:
Nationality:
Visa (when and where was opened):

Passports: Number Date of issue Place of issue Expiry date
Seaman's:
International:
Ukrainian:
Medical Test:
Drug & Alcohol test:
Yellow fever:
TAX number:

Height: Weight: Color: hair Color: eyes

Marital status:
Wife:
Children:
Home address:
Home phone:
Level of English language knowledge:

No. Name of Education Establishment Year of Entry Year of Graduation
1
2
3

Certificates: Speciality Number Date of issue Place of issue
Competency:
Endorsement:
Radiotelephone:
Endorsement:
Radar (ROPS):
Radar (ARPA):
Personal sea survival:
Ship's medical care Certificate:
Advanced fire fighting:
Carrying dangerous & hazardous:
Professionality in Survival Craft & Rescue Boats:
GMDSS:
Endorsement:
Others:

Sea Services During At Least Last Five Years:
Name of vessel Flag Type DWT Engine HP Owner Rank From Till
Years of sea experience:

Filling does not guarantee employment

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