S E A M A N ' s A P P L I C A T I O N F O R M SEAMAN'S PERSONAL DETAILS POSITION TO APPLY FOR CERTIFIED FOR NAME / SURNAME FATHER'S NAME MOTHER'S NAME D.O.B./P.O.B. NATIONALITY Height (in cm): Weight (Kg): Shoes size: Parka size: ADDRESS MOBILE No.: SKYPE ADDRESS: PHONE No.: E-MAIL: MARITAL STATUS MARRIED CHILDREN HOW MANY UNDER YES NO YES NO 18 YRS OLD …… NEXT OF KIN RELATION SEAMAN'S PASSP NO. ISS / DATE CIVIL PASSP NO. ISS / VALID DATE USA VISA ISS / VALID DATE GRADUATED FROM ENGLISH ABILITY FLUENT VERY GOOD GOOD FAIR B. NATIONAL CERTIFICATION CERTIFICATE NUMBER ISSUING - VALIDATION DATE ISSUING PLACE CERTIFICATE COMPETENCY OF ENDORSEMENT CERTIFICATE OF GMDSS (DECK OFF.) ENDORSEMENT OF GMDSS SHIP SECURITY OFFICER SDSD BASIC SAFETY PROFICIENCY IN SURV CRAFT MEDICAL FIRST AID ADVANCED MEDICAL CARE ADVANCED FIRE FIGHTING (DECK OFF.) ARPA (DECK OFF.) HAZMAT ECDIS LPG SAFETY LAST MEDICAL VACCINATIONS YELLOW FEVER : DOI……………..…… DOE ………………………. CHOLERA : DOI…………………. DOE ………………………. C. FLAG CERTIFICATION Based on NATIONAL FLAG TYPE / No. RANK ISSUED VALID ENDORSEMENT (S.BOOK/ENDORS/STICKER) NUMBER D. PREVIOUS SEA SERVICE VESSEL FLAG TYPE/DWT ENG/HP RANK S/ON S/OFF OWNERS
S E A M A N ' s A P P L I C A T I O N F O R M SEAMAN'S PERSONAL DETAILS POSITION TO APPLY FOR CERTIFIED FOR NAME / SURNAME FATHER'S NAME MOTHER'S NAME D.O.B./P.O.B. NATIONALITY Height (in cm): Weight (Kg): Shoes size: Parka size: ADDRESS MOBILE No.: PHONE No.: SKYPE ADDRESS: E-MAIL: MARITAL STATUS MARRIED YES NO CHILDREN YES NO HOW MANY UNDER 18 YRS OLD …… NEXT OF KIN RELATION SEAMAN'S PASSP NO. ISS / DATE CIVIL PASSP NO. ISS / VALID DATE USA VISA ISS / VALID DATE GRADUATED FROM ENGLISH ABILITY FLUENT VERY GOOD GOOD FAIR B. NATIONAL CERTIFICATION CERTIFICATE NUMBER ISSUING - VALIDATION DATE ISSUING PLACE CERTIFICATE OF COMPETENCY ENDORSEMENT OF CERTIFICATE GMDSS (DECK OFF.) ENDORSEMENT OF GMDSS SHIP SECURITY OFFICER SDSD BASIC SAFETY PROFICIENCY IN SURV CRAFT MEDICAL FIRST AID ADVANCED MEDICAL CARE ADVANCED FIRE FIGHTING (DECK OFF.) ARPA (DECK OFF.) HAZMAT ECDIS LPG SAFETY LAST MEDICAL VACCINATIONS YELLOW FEVER : DOI……………..…… DOE ………………………. CHOLERA : DOI…………………. DOE ………………………. C. FLAG CERTIFICATION FLAG TYPE / No. (S.BOOK/ENDORS/STICKER) RANK ISSUED VALID Based on NATIONAL ENDORSEMENT NUMBER D. PREVIOUS SEA SERVICE VESSEL FLAG TYPE/DWT ENG/HP RANK S/ON S/OFF OWNERS