Seaman Application Form Thank you — your application has been submitted successfully. Revision no.1 Shipcare Services Srl CONSTANTA – ROMANIA 6A ALEXANDRU PUSKIN STREET TEL: +40 722 704 493, +40 723 815 039, +40 760 150 213, +40 728 479 195 e-mail: office@shipcare.ro Attach a recent photo (upload below) 📷 Choose Photo SEAMAN’S APPLICATION FORM DATE: RANK APPLIED FOR:* AVAILABLE FROM: VESSEL: NAME IN FULL:* DATE OF BIRTH: PLACE: ADDRESS: E-MAIL:* PHONE: FATHER: MOTHER: CIVIL STATUS: Married Single Divorced NEXT OF KIN: ADDRESS: RELATIONSHIP: PHONE: CHILDREN’S NAMES IF ANY: ENGLISH: Good Adequate Poor PASSPORT No: ISSUE: EXPIRE: S. BOOK No: ISSUE: EXPIRE: GRADE OF NATIONAL LICENCE: NO: ISSUE: EXPIRES: CERTIFICATES ISSUED BY ROMANIAN NAVAL AUTHORITY NAME OF DOCUMENTNOISSUE DATEEXPIRE DATE Endorsement Tankers Certificate Oil Tankers Chemical Tankers LPG IMO VALID CERTIFICATES NAME OF IMO COURSENOISSUE DATEEXPIRE DATE Basic Offshore Safety Induction & Emergency Training Helicopter Underwater Emergency Training Basic Training for Oil and Chemical Tanker Cargo Operations Basic Training for Liquefied Gas Tanker Cargo Operations Advanced Training for Oil Tanker Cargo Operations Advanced Training for Chemical Tanker Cargo Operations Advanced Training for Liquefied Gas Tanker Cargo Operations Passenger Ships Basic Training for Oil and Chemical Tanker Cargo Operations – Refresher Basic Training for Liquefied Gas Tanker Cargo Operations – Refresher Advanced Training for Oil Tanker Cargo Operations – Refresher Advanced Training for Chemical Tanker Cargo Operations – Refresher Advanced Training for Liquefied Gas Tanker Cargo Operations – Refresher Hygiene Training for Catering Personnel Maritime Cook Specialization Human Element, Leadership and Management – Engine Department Ship Security Officer – Refresher Ship Security Awareness and Designated Security Duties Basic Safety Training Advanced Fire Fighting – Refresher Proficiency in Survival Craft and Rescue Boats (Other than Fast Rescue Boats) – Refresher Maritime English – Standard Phraseology Standard Training for Operation of Electronically Controlled Main Engines GMDSS General Operator’s Certificate – Refresher Medical First Aid Medical Care Prevention of Marine Pollution Transport and Handling of Dangerous Cargoes Radar Navigation, Radar Plotting and Use of ARPA Radar, ARPA, Bridge Team Management and Search and Rescue – Management Level Dynamic Positioning Marlins Test & Test of Spoken English Proficiency in Fast Rescue Boats ECDIS Transas – Generic & Type Specific Training Bridge Team and Resource Management Engine Team and Resource Management OTHER NATIONALITY / ADDITIONAL DOCUMENTS NoNATIONALITYNUMBERISSUEEXPIRE 1 2 ENDORSEMENT / SEAMAN’S BOOK OTHER DOCUMENTSISSUE DATEEXP. DATE Yellow Fever Card No / Valid USA Visa No MCV Visa No PREVIOUS SEA SERVICES (last five voyages, most recent first) NAME OF VESSELYEAR BUILTRANKTYPEDWTOWNER/MANAGERENGINE TYPE/HPFROMTILL BANK DETAILS NOMINATED BANK’S NAME: ACCOUNT HOLDER: IBAN CODE: SWIFT CODE: DECLARATION I, the undersigned, hereby certify that I have furnished all above information in good faith with the purpose of employment with your Company and that all the data is true and can be proven against my original documents (Passport, Seaman’s book, professional certificates of discharge), which I will produce at any time upon request by employing office, Master, Shipping Company and/or authorized authority. Should any discrepancy from above stated arise, I will be fully responsible for the resulting consequences, including, but not limited to, full charges and costs caused by such fact to involved parties for my employment and for immediate repatriation from the ship. In accordance with the General Data Protection Regulation (GDPR) (EU) 2016/679, I hereby give my explicit consent for Shipcare Services Srl to collect, process, and store my personal data submitted through this form, for the purpose of evaluating my application and, where applicable, my employment or engagement. I further consent that this data may be transferred to and processed by relevant third parties, including but not limited to shipowners, ship managers, manning agencies, and maritime authorities, to the extent necessary for the purposes of crewing, certification verification, and employment procedures. I confirm the above information is true and I accept the terms of this declaration.* SEAMAN’S SIGNATURE (type full name to sign electronically) Submit Application
