RUSAM MARITIME AGENCY LTD. Married. Country of issue. Remarks. National Licence. Other Flag License. Certificate/Endorsement. STCW Regulation No. Number /Type. ARPA / Radar

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RUSAM MARITIME AGENCY LTD

(Company certified for compliance with ISO 9001:2015 & MLC 2006)

50 Zoologicheskaya str., Kaliningrad, Russia

Tel. 8 (4012) 916-808 / 916-769/ 916-864/ 988-307

E-mail: cv@rusamagency.ru rusam@rusamagency.ru

www.rusamagency.ru

SEAFARER’S APPLICATION FORM (Form no.1 , Ver.9)

Name in full (First, Middle, Last) :

Rank :

PHOTO (please insert color / good quality photo )

Date & place of birth:

Nationality:

Marital status:

Single

Married

Divorced

Widower

Nearest Airport ( City / Country) :

Permanent Address( full style):

Tel:

Mob:

e-mail: skype:

Next of kin (surname, name, date of birth):

Relationship:

Address:

Mob: e-mail:

Children (surname, name, date of birth):

Hair / eyes (colour) :

Height (m):

Weight (kg)/ BMI:

Safety shoes size:

Safety overall size:

Education (name & city of educational institution, dates of entry / graduation and degree):

YELLOW FEVER VACCINATION CERTIFICATE :

Country of issue

Number:

Date issued:

Place issued:

Expiry Date:

Remarks

LICENCE INFORMATION (Certificate of Competency/Proficiency):

Country:

Grade of Licence:

Number:

Date issued:

Place issued:

Expiry Date:

National Licence

Other Flag License

OTHER CERTIFICATES AND ENDORSEMENT INFORMATION:

Certificate/Endorsement

STCW Regulation No

Number /Type

Date issued:

Place issued:

Expiry Date:

GMDSS ( GOC / ROC)

A-IV/2

ARPA / Radar

A-II/1, A-II/2

ECDIS

B-I/12

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