CREW DATA SHEET - Sea Jobs COLUMBIA SHIPMANAGEMENT LTD
PERSONAL DATA Date: 20/07/2010 NAME: Brcic Ivan
This application form has to be completed by the Crewing Agent or CSM Representative prior joining
Instructions:
Required Initially Not Required For Deck Engineers & Personel Only
PERSONAL DETAILS
Position: 3rd Mate Alternative: 3rd Mate
Vessel: M/V Fennela Flag: Bahamas
Surname: Brcic
First Name: Ivan Middle Name: / Photo
D.o.B.: 12/23/1988 P.o.B.: Split
Nationality: Croatian Sex : male
Civil Status: / No. of Children / Dependent: /
ADDRESS
Street: Kralja Kresimira 30 Tel: 021-221-358
City: Kastel Kambelovac Tel:
Country: Croatia Fax:
Airport: Split -Kastela E-mail: ivanbrcickk@[Link]
NEXT OF KIN
Name: Vinko Brcic Tel * : 021-221-358
Relation: father Fax * :
Street: Kralja Kresimira 30
City / Country: Kastela/Croatia * If same as above, please insert "As above"
NATIONAL IDENTITY DOCUMENTS / VISA
Passport No: 3092643 Issued: 06.12.2006. Expired: 12/6/2011
SB-Book No: 43329 Issued: 1/4/2008 Expired: 1/4/2018
US - VISA: 87352181 Issued: 4/9/2008 Expired: 4/7/2013
Other Visa: Issued: Expired:
LANGUAGES
Level of English very good Test passed Date :
Mother Language croatian Remarks
Other Language
MEDICAL EXAMINATION ( HEALTH CERTIFICATES)
Clinic: Specialised practice Mirjana Antunovic Issued: 11/16/2009 Expired: 11/16/2011
VACCINATIONS (VALID FOR DURATION OF CONTRACT)
1. SHOT [Link] [Link]
Cholera: Yellow Fever: yes Typhoid: Tetanus: Hepatitis B:
DRUG AND ALCOHOL TEST
NEG POS
Clinic: Specialised practice Mirjana Antunovic Issued: 11/16/2009 Result: neg
IF TEST RESULTS ARE POSITIVE, PLS STATE REASON (E.G. PRESCRIBED MEDICATION ETC.)
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CREW DATA SHEET COLUMBIA SHIPMANAGEMENT LTD
EXPERIENCE Date: 21/07/2010 NAME: Brcic, Ivan
This application form has to be completed by the Crewing Agent or CSM Representative prior joining
TRAINING COURSES (All Training courses / Seminars / Upgrading courses other than STCW/Flag state requirements)
Training Course / Seminar Location Duration Date
GRADUATED FROM :
FORM OF EDUCATION
WORKING CLOTHES : Overall size/Safety shoes size Height
SEA SERVICE (Complete sea service record for at least last 10 employments)
Flag Type Engine Company S/on Months/
Name of vessel Rank
Year built GRT kW Crew Agent S/off Days
30/11
30/11
30/11
30/11
30/11
30/11
30/11
30/11
30/11
30/11
30/11
30/11
Page 2
CREW DATA SHEET Date: COLUMBIA SHIPMANAGEMENT LTD
QUALIFICATION STCW-95 and CSM NAME: Brcic, Ivan
This application form has to be completed by the Crewing Agent or CSM Representative prior joining
IMO Course
1. BASIC SAFETY TRAINING STCW (A-VI/1) (Revalidation is not required)
1.22
No DATE OF ISSUE No DATE OF ISSUE
PERSONAL FIRE
1.1 SURVIVAL
1.3 FIGHTING
No DATE OF ISSUE No DATE OF ISSUE
ELEMENTARY PERSONAL
1.2 FIRST AID
1.4 SAFETY
2. STCW - ADDITIONAL TRAINING (A-VI/2 ~ 4) (Revalidation is not required)
No DATE OF ISSUE No DATE OF ISSUE
RESCUE MEDICAL
2.1 BOATS
2.4 FIRST AID
No DATE OF ISSUE No DATE OF ISSUE
FAST RESCUE
MEDICAL
2.2 2.5 CARE
BOATS No DATE OF ISSUE
ADVANCED
2.3 FIRE
FIGHTING
3. CERTIFICATE OF COMPETENCY (A II/1-4, A III/1-4) Officers and watchkeeping ratings
No DATE OF ISSUE DATE OF EXPIRY(officers only)
3.1 CAPACITY
4. OTHER CERTIFICATES
No DATE OF ISSUE DATE OF EXPIRY Type (GOC or ROC)
4.1 GMDSS
SCORE DATE OF TEST DATE OF ISSUE
Ship Security
4.2 Marlins Test 4.4 Officer Ship Simulator and Bridge
Teamwork course.
DATE OF ISSUE DATE OF ISSUE Bridge Team Management
Ship's Handling or Bridge
4.3 Planned Maintenance Program 4.5 Resourse Management
courses with the use of Full
mission Bridge Simulator.
(Specify type)
5. SPECIAL REQUIREMENTS TANKER (A V/1)
No DATE OF ISSUE No DATE OF ISSUE
Shore based Oil Tanker
5,0 Fire Fighting
5.2 Advanced
No DATE OF ISSUE No DATE OF ISSUE
Chem Tanker
TANKER
5.1 Familiarization
5.3
Advanced No DATE OF ISSUE
Gas Tanker
5.4 Advanced
No DATE OF ISSUE No DATE OF ISSUE
5.5 COW 5.6 Inert Gas
6. SPECIAL REQUIREMENTS PASSENGER (RO-RO PAX VESSELS (A V/2, AV/3) (refresh required every 5 years).
No DATE OF ISSUE No DATE OF ISSUE
Crowd Safety
6.1 Management
6.3 Training
No DATE OF ISSUE No DATE OF ISSUE
Familiarization Pass. safety
6.2 Training
6.4 Cargo safety
No DATE OF ISSUE
Crisis mngm
6.5 Human Behvr
No DATE OF ISSUE COVERING FOLLOWING PARAGRAPHS
TO BE COMPLETED IN CASE THE
COMBINED CERTIFICATE COVERS MORE THAN ONE
6.6 CERTIFICATE TRAINING OF THE ABOVE MENTIONED.
7. SPECIAL REQUIREMENTS DRY CARGO VESSELS CARRYING DANGEROUS CARGO
No DATE OF ISSUE
7.1 HAZMAT
8. ANY OTHER ADDITIONAL QUALIFICATIONS
9. FOR OFFICE USE (Authenticity of documents as per section 3 checked)
Name and Signature please.