Тел.: +(38048)785-47-01
Факс: +(38048)785-47-02
agency@maxmarin.od.ua

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"MAXMARINE", LLC - shipping agency, crewing, freigt forwarding, chartering  (Odessa, Theodosia, Mariupol, , Illychevsk, Kerch,  Nikolaev, Izmail, Reni, Ukraine)

 APPLICATION FORM

Position applied for: Second choice:
Date Available Expected salary:
Surname Name
Father`s Name Nationality
Date of Birth Place of Birth
Contact Phone Mob. Phone
Address
Next of Kin Name Addres Next of Kin
Relationship Phone
Number of children under 18 E-mail
Education Name of maritime college or academy From Till
Licenses Number Endor. Issue Endor.Validity Diploma Issue Place of Issue
GMDSS sertificate
Passports Number Date of Issue Validity Place of Isue
Seaman`s identification card
Seaman`s book
Foreign civil passport
Certificates Number Date of Issue Validity
Basic safety course (Section A-VI/1 STCW Code95)
Advanced fire fighting (Section A-VI/3 STCW-Code95)
Proficiency in survival craft (Section A-VI/2 STCW-Code95)
Radar Navigation Certificate
ARPA/Radar Observing Certificate
Hazardous Cargoes (Section B-V/4&B-V/5 STCW-Code95)
Security officer certificate (ISPC Code)
Safety officer certificate (ISM Code)
Ro-Ro certificate
Crowd management certificate
Crude Oil Washing Certificate (MARPOL 73/78)
Inert gas system certificate
Health List (Medical Certificate)
Yellow Fever Vaccination Card
USA Visa
Other certificates
Other certificates
Applicant's Weight, Height, Sizes, Special Peculiarities Language knowledge
Weight Height Eyes Hair Shoez size Overall size English level German level
Vessel Type
Dwt
Eng.Type
BHP
Flag
Port of Reg
Owner
Crewing
Rank From
(dd/mm/yy)
Till
(dd/mm/yy)
Note: (A) Have you ever been denied a foreign visa?
(B) Have you been the subject of a court of inquiry or involved in an accident?
I hereby affirm that all the information provided by me in this FORM is TRUE and CORRECT to the best of my knowlege.
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