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Seaman's Application Form Template

This document is a seaman's application form containing personal and certification details. Section A includes the applicant's name, date of birth, nationality, address and English proficiency. Section B lists national certificates held, including safety training and medical information. Section C is for flag-state certification such as endorsements from ship registry authorities. Section D is for recording previous sea service experience on other vessels.

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Dmitriy
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24 views1 page

Seaman's Application Form Template

This document is a seaman's application form containing personal and certification details. Section A includes the applicant's name, date of birth, nationality, address and English proficiency. Section B lists national certificates held, including safety training and medical information. Section C is for flag-state certification such as endorsements from ship registry authorities. Section D is for recording previous sea service experience on other vessels.

Uploaded by

Dmitriy
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

SEAMAN's APPLICATION FORM

MARINE PRO SERVICE


foto

A. SEAMAN'S PERSONAL DETAILS

POSITION TO APPLY FOR CERTIFIED FOR


NAME / SURNAME
FATHER'S NAME MOTHER'S NAME
D.O.B./P.O.B. NATIONALITY
ADDRESS
MOB:
MARITAL STATUS MARRIED CHILDREN HOW MANY UNDER
YES  NO X YES  NO X 18 YRS OLD NO
NEXT OF KIN RELATION
SEAMAN'S PASSP NO. ISS / VALID DATE
CIVIL PASSP NO. ISS / VALID DATE
GRADUATED FROM
ENGLISH ABILITY FLUENT  VERY GOOD  GOOD X FAIR 

B. NATIONAL CERTIFICATION
CERTIFICATE NUMBER ISSUING - VALIDATION ISSUING PLACE
DATE
CERTIFICATE OF COMPETENCY
ENDORSEMENT OF CERTIFICATE
BASIC SAFETY
PROFICIENCY IN SURV CRAFT
DANGEROUS SUBSTANCES
LAST MEDICAL
VACCINATIONS YELLOW FEVER : DOI………….................… DOE …....................……….
CHOLERA : DOI………………………. DOE ……………………….

C. FLAG CERTIFICATION
Based on NATIONAL
FLAG TYPE / No. RANK ISSUED VALID ENDORSEMENT
([Link]/ENDORS/STICKER) NUMBER

D. PREVIOUS SEA SERVICE


VESSEL FLAG TYPE/DWT ENG/HP RANK S/ON S/OFF OWNERS

Version: 7/03 Seaman’s Signature……………………………

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