MAGELLAN MARINE GDYNIA
POLAND 81-312 Gdynia
Olsztyńska 30a/1
crew@magellanmarine.pl
phone: +48 58 661 90 16
fax: +48 58 661 90 18
SEAFARER'S APPLICATION FORM
Rank
Ready from
Expected wages
Family Name
First Name
Father`s Name
Date of Birth
Place
Nationality
Permanent
address
Tel. Number 1
Tel. Number 2
Marital Status
Wife`s Name
Children/Age;
Education 1
E-mail
Passport No
Issued in
Issued on
Valid till
Seaman`s
Book
Issued in
Issued on
Valid till
Licence as
Issued in
Issued on
Valid till
Licence no
Language
Knowledge
Date of first seagoing experience
1.
Total experience at requested rank
2.
Date of first command of the v/l (Masters)
3.
Date of first command of E/R (Ch.eng.)
CERTIFICATE
Issued at
Issued on
Valid till
Personal Survival Techniques
Fire Fighting - Advanced
Fire Fighting - Basic
Medical Care
Medical First Aid - Advanced
Medical First Aid - Basic
Personal Safety and Social Resp.
Proficiency in Survival Craft
ARPA
Radar Observer
GMDSS NR
HAZMAT
US Visa
Ship Security Officer (SSO)
Other/Flag Docs
Other/Flag Docs
Other/Flag Docs
Yellow Fever Vaccination
Other
Nearest airport
PREVIOUS SEA SERVICE
VESSEL
NAME
FLAG
VESSEL
ENGINE
AGENCY
FROM
TO
RANK
SIGNING
OFF
REASON
TYPE
DWT
TYPE
HPS
LAST EMPLOYMENT
NAME OF MANAGERS / OWNERS
PHONE NUMBER INCL. COUNTRY AND AREA CODE
NAME OF PERSON TO CONTACT
NEXT OF KIN
NEXT OF KIN NAME
NEXT OF KIN ADDRESS
NEXT OF KIN PHONE NUMBER
OŚWIADCZENIE
Zgodnie z Ustawą z dnia 29 sierpnia 1999r. o ochronie danych osobowych (Dz.U. nr 133/97 poz. 883) wyrażam zgodę na przetwarzanie moich danych osobowych przez firmę Magellan Marine Gdynia w celach i na potrzeby pośrednictwa pracy. Zgadzam się na wysyłanie moich danych za granicę do armatorów oferujących pracę polskim marynarzom. Zostałem poinformowany/a o możliwości wglądu do w/w danych.
Service Agreement: I hearby agree to allow Magellan Marine Gdynia to store and publish the details which I have given in this form and in my attached CV, together with the understanding that Magellan Marine Gdynia may charge a third party to view these details.
DATE
SIGNATURE
contact:
crew@magellanmarine.pl
december 2003, 3net
SEAFARER'S APPLICATION FORM