12 Gapsal’skaya str of 103 198035 St Petersburg Russia Tel Fax 7 8

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12 Gapsal’skaya str of 103 198035 St Petersburg Russia Tel Fax 7 8 Powered By Docstoc
					                                         12, Gapsal’skaya str., of. 103
                                         198035 St.Petersburg, Russia
                                           Tel/Fax: +7(812)714-94-85
                                             Web: www.oandk.ru                                   ISO 9001-2000
                                           e-mail: oandk.crewing@gmail.com

   DATE AVAILABLE:                                   USA VISA VALID:

1. PERSONAL DETAILS
  POSITION APPLIED FOR:                              WISH SALARY:

             SURNAME:

   FIRST/MIDDLE NAME:

   DATE/PLACE OF BIRTH:

          NATIONALITY:

   PERMANENT ADDRESS:

      NEAREST AIRPORT:

                 PHONE:

       MARITAL STATUS:

    EDUCATIONAL BODY:                                                     YEAR FROM / TO:               /



      WEIGHT:             KG              EYES COLOR:                              SHOES SIZE:

       HEIGHT:            SM              HAIR’S COLOR:                          CLOTHES SIZE:

2. NEXT OF KIN
             SURNAME:                                            RELATIONSHIP:

           FIRST NAME:                                    DATE/PLACE OF BIRTH:

   PERMANENT ADDRESS:

                 PHONE:

3. PASSPORT DETAILS
                          COUNTRY    SERIES     NUMBER       ISSUE DATE      ISSUE PLACE         VALID UNTILL

        CIVIL PASSPORT:    RUS
      TRAVEL PASSPORT:     RUS
    SEAMAN’S PASSPORT:     RUS
        SEAMAN’S BOOK:



4. LICENCE PARTICULARS
                                 GRADE        NUMBER         ISSUE DATE          ISSUE PLACE      VALID UNTILL

          NATIONAL LICENCE:

        GMDSS ENDORSEMENT:

   OIL TANKER ENDORSEMENT:

 CHEM. TANKER ENDORSEMENT:

   GAS TANKER ENDORSEMENT:
            FOREIGN COUNTRIES               GRADE              NUMBER            ISSUE DATE             ISSUE PLACE      VALID UNTILL
                ENDORSEMENTS
                 ENDORSEMENT:

                 ENDORSEMENT:

                 ENDORSEMENT:

5. CERTIFICATION
                                            GRADE              NUMBER            ISSUE DATE             ISSUE PLACE      VALID UNTILL

                BASIC TRAINING :
     PROFICIENCY IN SURVIVAL
                      CRAFT:
     ADVANCED FIRE FIGHTING:
              MEDICAL FIRST AID
           or/and MEDICAL CARE:
           GMDSS CERTIFICATE:
  RADAR OBSERVER & PLOTTING
                  TRAINING:
                           A.R.P.A:
   BRIDGE TEAM MANAGEMENT
                CERTIFICATE:
       HAZARDOUS MATERIALS
                CERTIFICATE:
       HAZARDOUS MATERIALS
           CERTIFICATE (USA):
           OIL CRUDE TANKER
                CERTIFICATE :
   CHEM.TANKER CERTIFICATE:

     LPG TANKER CERTIFICATE:

   SHIP SECURITY CERTIFICATE:

  YELLOW FEVER VACCINATION:

          OTHER CERTIFICATES:

 MEDICAL FITNESS CERTIFICATE

6. PREVIOUS SEA EXPERIENCE (FOR LAST 5 YEARS)
                             YEAR OF         TYPE OF                          DWT+TEU/      ENGINE                    SHIPOWNER/CONTACT
    NAME OF VESSEL                                      FLAG       RANK                               FROM     TO
                              BUILD          VESSEL                             BHP*         TYPE                          NUMBER




 * DWT +TEU for deck department; BHP (kW) for engine department.                                   Months             Nationality

               Whether agreeable to one rang lower:          Experience with multinational crew:



                DATE :                                                     SIGNATURE:

				
DOCUMENT INFO
Description: Medical Certificate of Fitness Russia document sample