SHOKK Service Marine Agency Ltd by HC12092900445

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									                                SHOKK Service Marine Agency Ltd.
                                   6, Gagarina str., Mariupol, 87510, Ukraine
        Phone:(380)(629) 476666, 476667, 476668; Fax:(380)(629) 476669 ; E/Mail: shokk@shokk.biz; Web:
                                                www.shokk.biz




                                           FOR SEAFARERS ONLY!
                                                APPLICATION
                                          (28 September 2012 17:18)

 RANK:                              ID №:                        ALT/POSITION:
 Surname:                                Name:                            2-nd name:
 Date of birth:                  Place of birth:                          Nationality:
 Phone:                                        Country:                           Post code:
 Apart:                 Street:                                              City:
 Seaman's Book №:                                      Issued:                      Valid:
 Civil passport №:                                     Issued:                      Valid:
 Citizen passport №:                                   Issued:
 Registration:
 Other passport (LIBER./PANAMA/ or other):
 Height:               cm    Weight:                 kg Uniform Size:                   Foot Size:
 Yellow fever:                                                   American visa:
 DOCUMENTATION
                     Education1:                           Date:                       Grade:

                     Education2:                         Date:                         Grade:

     № Cert 1:          Date:           Place:                                  Grade:

     № Cert 2:          Date:           Place:                                  Grade:

 English:                       Other language:                                       AT SEA:
                                             №:             Issued:        Valid:                 Place:
 Endorsement:
 F. F. T.:
 Proficiency in survival craft:
 Advanced fire fighting:
 Advanced medical first aid:
 Medical care:
 Radar /ARPA:
 GMDSS:
Cert. Of Competency for rank/Flag                                       Grade/Country:                  /
    RANK          VESSEL                   MANAGER / OPERATOR              Type of vessel       DWT /       Period
                                      (Name, Contact Phones/Fax/E-Mail)        / ME             Power         of
                                                                                                            service




 READINESS:                                       LAST SALARY(USD):

								
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