ALPHA MARINE CREW SERVICE LTD.,

4, MALOZEMELSKAYA STR., NOVOROSSIYSK, 353922, RUSSIA
TEL/FAX NRS: +7 (8617) 60-73-08/60-73-09
EMAIL:ALPHAMARINE@NVRMAIL.RU

APPLICATION FOR SHIPBOARD EMPLOYMENT

RECORD OF FULL DATA

RANK: DATE: NATIONALITY: RUSSIA

Full name:

Date of birth: Place of birth:

Place of birth:

Father's name: Mother's name:

Home address:

PhoneNo: Mobile:

Civil status: Single Married Divorced Widower No. of children:

Name of next of kin Relationship:

Address of next of kin:

Phone of next of kin:

Educational background:

Secondary school:
College:
Highest educational attainment:

Licence Nr:	Place	Date	Valid to
Endorsement Nr:	Place	Date	Valid to
Interior passport Nr:	Place	Date	Valid to
Seaman's passport Nr:	Place	Date	Valid to
Foreign passport Nr:	Place	Date	Valid to

VISA/Valid to:
Any flag state's license/Valid to

English level:Other languages:

Cargoes worked with (applicable for deck officers)
Highest national certificates

Certificates	Number	Date issued	Place issued	Valid to
GMDSS(GOC)
GMDSS(endorsement)
Radar Observation and P.S.
A.R.P.A.
Ship's security officer
Ship's safety officer
Bridge team managment
Bridge team resources managment
Ship's handling and manoeuvring
STCW 78/95 reg. VI/I-Approved basic safety training course (PST, FP&FF, EFA, PS&SR)
Medical care
Medical first aid
Advanced Fire Fighting
Proficiency in survival craft
Tanker familiarization training (OIL)
Specialized tanker training (oil) COW, IGS, VRS
Dangerous Cargoes
ISM, QSEMS, ISPS Code (Company training)
Ship to Ship Service Vessel Experience	Yes no
Ship to Ship STBL Vessel Experience	Yes no
Cargo-ballast operation simulator
Anti-alcohol/drug test
Health Certificate
Yellow Fever
Highest Flag State Cetificate
Flag State Seaman's Identification document

Training sources/Seminars	Place	Date
ISM Code
Framo courses
OPA 90
Engine Room Resources managment
Company's Seminars
English languege courses

Please enumerate below your sea experience. Employment Record For Last Five Years
Name:

Type and Name of Vessel	DWT/Engine BHP makers	Company's name	Phone No/Crewing Agent's Name	Position	Period of service (from/to)	Reason of discharge

Please enumerate below other employments not connected with sea

From/to	Position	Company	Type of work	Reason of leaving

Present employment:

Note Please attach service record to support above statement
I, herby, certify that all entries are true and I authorize ALPHA MARINE CREW SERVICE LTD., to gather such additional
informationof verify such details as may be necessary for purpose of considering me an applicant for employment.
Any false statement ormisinterpretation in this application shall be ground for dismissal subsequent to employment.

Я, ниже подписавшийся, подтверждаю, что вся информация правдива и предоставляю право "ALPHA MARINE CREW SERVICE LTD.,"
собирать любую дополнительную информацию и выяснять необходимые для моего дальнейшего трудоустройства детали.
Любые недостоверные данные или неверное истолкование данных могут служить причиной отказа в предоставлении трудоустройства.

Re your report our office, please mark the way through as appropriate:

Which one/channel: Newspaper T.V. Radio Acquaitances No means