Seafarer Application Form

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Seafarer Application
Passport
DÖHLE MANING AGENCY (POLAND) LTD
photo
10 Lutego str.10 ,PO Box 379, 81-301 Gdynia 1,
Tel: +48 58 660 6099 , +48 58 660 8066 ,Fax: +48 58 660 5770 ,
E-mail: ,
Rank
Surname
1st Name(s)
Date of Birth
Place of Birth
Nationality
Marital Status
No. of Children
Phone
Mobile Phone
Full Address
E-Mail Address
Nearest Airport
Availability Date
Next of kin
Relationship
Phone
Address
Education
Year completed
Identity-/ Travel Documents
Nationality
Type
Number
Place of Issue
Issued
Expiry
Passport
US-Visa
Other Visa
Seaman Book
Seaman Book
Medical Certificates
Nationality
Type
Number
Place of Issue
Issued
Expiry
Certificate of Medical Fitness
Yellow Fever Vaccination
Certificates - Courses
Nationality
Position
Number
Place of Issue
Issued
Expiry
Certificate Of Competence
Certificate Of Competence
Certificate of SSO
General Operator Cert. (GMDSS)
Basic Safety Training
Proficiency Survival Craft
Proficiency Fast Rescue Boats
Advanced Fire Fighting
Medical First Aid
Medical Care
HAZMAT (US-Trading)
ARPA
ECDIS
Experience-Knowledge
Subject or Hard- / Software
Self Evaluation (please tick)
Language Knowledge
English
Good
Satisfactory
Nil / Poor
Language Knowledge
Good
Satisfactory
Nil / Poor
Electr. Chart Display System
Good
Satisfactory
Nil / Poor
Computer Experience
Microsoft Windows
Good
Satisfactory
Nil / Poor
Computer Experience
Microsoft Office (Word, Excel)
Good
Satisfactory
Nil / Poor
Stability / Cargo Planning System
Seacos
Good
Satisfactory
Nil / Poor
Other Stability / Cargo System
Good
Satisfactory
Nil / Poor
Planned Maintenance System
CODie ISMAN
Good
Satisfactory
Nil / Poor
Other Planned Maintenance Syst.
Good
Satisfactory
Nil / Poor
Working Experience
Monitor / Maintain Reefer Containers
Good
Satisfactory
Nil / Poor
Working Experience
Operate / Maintain Ship's Cranes
Good
Satisfactory
Nil / Poor
Working Experience
Automation Systems
Good
Satisfactory
Nil / Poor
Working Experience
Common Rail M.E.
Good
Satisfactory
Nil / Poor
Working Experience
ISM - Systems / - Audits
Good
Satisfactory
Nil / Poor
Please state Nationalities of Seafarers you sailed with:
Senior Officers
Junior Officers
Ratings

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