Title: Form Manual
Operational Procedures
Form
MSC CREWING SERVICES MSC House, 92-v Lustdorfskaya road, Odessa 65088, Ukraine Tel.: +38 (0482) 333 891 Fax.: +38 (048) 7055 200 / E-mail: info@msccs.com
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APPLICATION FORM (Personal Data)
Position applied for __________________ License hold ___________________ Date Available __________
Family Name: Date of birth: Address:
Name: Place of birth:
Next of kin and relationship: Next of kin’s address: Inter. P’port No : Seaman's book No : Civil P’port No : USA visa No : TOSE :
Father's name: Nationality: Marital status: Nearest Airport: Home phone: E-mail: Mobile phone: Children (name & DOB): Next of kin tel: Valid: Place of issue: Valid: Place of issue: Place of issue: Valid: Place of issue: MARLINS, %: Date of issue:
Date of issue: Date of issue: Date of issue: Date of issue: Date of issue:
SEA GOING EXPERIENCE FOR THE LAST 7 YEARS (MOST RECENT VESSEL LAST)
Name of vessel
Version 00/01 Feb 19
Year of built
Company Owner / Ship Manager
Flag
Type of vessel
Page 1 of 2
DWT / TEU
ME type / Model
BHP
Rank
From DD/MM/YYYY
Form CD-P03-1
To DD/MM/YYYY
Title: Form Manual
Operational Procedures
Form Name of Maritime Institution attended
STCW Certificates Certificate of competency Endorsement GMDSS Endorsement Radar obs./ARPA operator ECDIS course Security officer (ISPS) Security Designated Duties Hazardous cargoes
Medical examination Drug & alcohol test Yellow fever Another States Seamen’s Books Liberia Panama
Number
Address of institution
Issued
Valid
Issued: Issued: Issued: Rank
Document No
From
Place of issue
STCW Certificates BRM or ERRM Course Basic safety for all seafarers Advanced fire fighting Prof. in survival craft Fast rescue boat Medical first aid Medical care Training pers on pass.ships
Valid: Valid: Valid: Issued
Valid
To
Number
Weight, kg: Eyes: Overall size: Another States Certificates of competency Liberia Panama
Degree of Diploma
Issued
Valid
Place of issue
Height, cm: Hair: Safety shoes: Rank
Document No
Issued
Valid
Please complete addresses of your previous employers for references
Company Address
Tel
Company Address
Tel
Мій підпис підтверджує мою остаточну та безсуперечну згоду на обробку (збір, накопичення, зберігання, прийняття, систематизацію, використання, розподіл, поновлювання, змінення, знищення, кодування та будь-які інші дії, необхідні для надавання посередницьких послуг з найму за кордоном і/або інших супровідних послуг) моїх особистих даних, що вказано в цій заявці з найму, а також будь-яких інших моїх особистих даних, що надаються до ТОВ «ЕМ ЕС СІ КРЮЇНГ СЕРВІСЕС»
Version 00/01 Feb 19
Page 2 of 2
Form CD-P03-1
Title: Form Manual
Form Signature____________________ Date ________________
Operational Procedures
I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.
Nationalities of crew sailed with:
Version 00/01 Feb 19
Page 3 of 2
Form CD-P03-1