Atlantic ship management

Application Form

Surname/Фамилия:_________________________Father’s Surname/Name/ФИО Отца:_______________________

Forename/Имя:____________________________ Mother's Surname/Name/ФИО Матери:____________________

Date of Birth/Дата рождения:_____________ Place of Birth/Место рождения:_______________________

Home Address/Адрес прописки:___________________________________________________________________

Postal Code/Индекс: _______________ Home tel./Дом.т.: ____________ Mobile/моб.т.:______________

Marital Status:___________Height/Рост:_____Weight/Вес:…___Cloth size/Разм.одежды:___________

Shoes size/Разм.обуви:_________Education(Name of Marine School)____________________________________________

Гражданский паспорт: Cерия_____________Дата выдачи…______________Кем выдан_____________________

Идентификационный код: ______________ Количество детей до 18 лет_____________________________

Ближайший родственник: _______________ Адрес/тел: ____________________________________________

DOCUMENTS	Number	Issued	Photo Valid
Seaman's Passport
International Passport
Yellow Fever
USA Visa

LICENSES		Number	Issued	Valid
Certificate of Competency
Endorsement
GMDSS
Endorsement GMDSS
Medical First Aid or Medical Care
Ship Security Officer
Survival Crafts
Basic Safety Training
Advanced Fire Fighting
ARPA and RADAR
FLAG STATE DOCUMENTS	Cyprus License
	Cyprus Seaman’s Book
	Maltese License

PREVIOUS SEA EXPERIENCE (FOR THE PAST 5 YEARS)

Appraisal/Promotion report (yes/no)/Характеристики …………………………