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Last  salary

Application Form Engineers

Personal Data

Surname	Name	Father's Name	Permanent address:
Citizenship	Date of birth	Place of birth	Phone:
Mobile:
E-mail:
Document	No.	Date of issue	Place of issue	Valid until
Passport (Travelling)
Seaman’s Book
Ukrainian Civil Passp
Liberian S. B.
Panamanian S. B.
Singapore
Other

Visas

Country	Visa Type/Class	No.	Date Issued	Place Issued	Valid Until
USA
Australia
Singapore

Marine Education

Full Name of School	Qualification	From	Till

Sea experience (Last 5 years)

№	Rank	Vessel	Flag	Year of build	Type of vessel	D. W.T	Owner or Management Co /Country	From / To	Reason of departure
1
2
3
4
5
6
7
8
9
10

№	Automation (A1/A2)	Main Engine Maker / Model	Engine Stroke	Engine Total HP/KW	Aux. Engine Maker / Model	Aux. Engine HP/KW	Experience	Crew
Unmanned Yes/No	With El. Eng Yes/No
1
2
3
4
5
6
7
8
9
10

Highest Competency certificate held:

Issuing authority

Grade/ STCW’95 Capacity

Certificate No.

Date of issued

Valid until

National  Certificate of Comp

STCW 78/95 Endorsement

Liberian

Malta

Panamanian

MPA Singapore

Other

Certificates/Courses

Certificates of STCW 78/95	Number	Date of issue	Place	Expiry date
Basic Safety Training and Instruction (A-VI/1)
Carrying Dangerous & Hazardous cargo (B-V/b, B-V/c)
Advanced Fire Fighting (A-VI/3)
Proficiency in Survival Craft, Rescue Boats (A-VI/2-1)
Medical First Aid (A-VI/4-1)
Maintenance of Electrical and Electronic Engineering
Process Control Instrument
Ship safety officer IMOA 741(18)
Ship Security Officer (STCW A – VI/5 and ISPS Code)
Security Awareness (A-VI/6-1)
Designated Security Duties ( A-VI/6-2)
Engine Automation
Engine Team and Resource Management
Ro-Ro passenger ships
Crowd  management ( A-VI/2)
Familiarization  training  Ro-Ro ships (A-V/2)
Safety Training ((for personnel providing direct service to passengars)
Passengers safety cargo safety, hull integrity  ( A-V/2)
Crisis management and human behavior ( A-V/2)

Tanker Certificates	Number	Date of issue	Place	Expiry date
Tanker familiarization course (V/1)
Oil/Chemical Tanker specialized training (A-V/1, c.15-21)
Liquefied gas Tanker specialized training (A-V/1, c. 22-34)
Oil Tanker specialized training (A-V/1, c.8-14)
Crude oil washing (STCW 3/9)
Inert gas system (MARPOL 73/78)
Shore - based fire - fighting course (V/1)

7.Additional information

English language	Excellent	Good	Satisfactory	Poor
Computer proficiency	Excellent	Good	Satisfactory	Poor

Nationalities of crew sailed with: 

Bank details

Next of Kin

Marital Status

Overall, height, weight, shoes size

Medical Certificates included yellow fever, cholera

Nearest airport

English - Marlin/Ces 4.1 tests

Please complete addresses of your previous employers for references

Company	Tel.:	Company	Tel.:
Address	Address

I certify that above information is true and accurate to the best of my ability and that no Certificate of Competency, Licenses or Visas issued to me has ever been revoked or suspended.

I have been advised and agree to recover expenditure of Shipowner and/or Crewing Agency, which can be occurred due to wrong information or faulty documents from me.

I understand that previous employers may be asked for information concerning my Employment record with them and I hereby release from all liability or damage those individual or companies who provide such information

Signature____________________  Date ______________­__

  Я,                                                , в соответствии с Законом Украины «О защите персональных данных» от 01.06.10 , даю свое согласие на включение моих персональных данных в БПД «КЛИЕНТЫ» -Стрим, ЛТД» в виде картотеки и/или автоматизированной информационной системы, а также на их обработку (сбор, регистрацию, накопление, бессрочное хранение, изменение, обезличивание, уничтожение, обновление, адаптацию,  использование, распространение, реализацию, передачу в полном объеме или частично распорядителям или третьим лицам) без дополнительного письменного уведомления об этом в мой адрес, с целью оказания предприятием посреднических услуг по моему трудоустройству на судах отечественных или иностранных судовладельцев, независимо от страны их местонахождения. 

Я письменно уведомлен о включении моих персональных данных в БПД «КЛИЕНТЫ» -Стрим, ЛТД», о ее местонахождении и целях сбора данных, о лицах, которым будут  передаваться мои персональные данные и о моих правах в связи с этим

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