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PALMALI Saint-Petersburg. PALMALI Rostov-na-Donu. PALMALI Novorossiysk. APPLICATION FORM. Personal ID Number. 1. Personal Data. 2. Maritime Education. 3. Professional Test. 4. Family Details. 5. Identity Documents. 6. Valid Visa. 7. Courses Attended and C

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PALMALI Saint-Petersburg

Phone: +7 812 335 66 99/97; Fax: +7 812 335 66 98; e-mail: hr@palmali. spb. ru

PALMALI Rostov-na-Donu

Phone: +7 863 268 81 94; Fax: +7 863 268 81 98; e-mail: kadry@palmali-r. ru

PALMALI Novorossiysk

Phone: +7 8617 60 59 57; Fax: +7 8617 60 57 47; e-mail: palcrewing@palmalinovo. ru

 

APPLICATION FORM

                       

Personal ID Number

 

Position Applied for:   Date Available from:  

 

1. Personal Data

Family Name: First Name: Middle Name:
Date of Birth: Place of Birth (City and Country): Citizenship:

Permanent Address:   

Phone (Home): Phone (Business/ Mobile): E-mail:  

 

2. Maritime Education

Name of school Town Country From To Type of degree or diploma
           
           
           
           

 

3. Professional Test

English Test Date Name of Test Score
Professional Test Date Name of Test Score
Professional Interview Date

Result

 

4. Family Details

Civil Status (Single, Married, Separated, Divorced, Widowed):    
Next of Kin (the first emergency contact)   Relationship
Address of Residence    Phone  

 

           
Family Name          
First Name          
Date of Birth          
City of living          
Phone Numbers          

 

5. Identity Documents

Document Country Number Place of Issue Issue Date Expiry Date
Seaman's Book          
Travel Passport          
Civil Passport          

 

6. Valid Visa

Country or Union Type Valid Until
     
     

 

7. Courses Attended and Certificates Obtained

Document

Number

Dates

Place

Issue Expiry
         

 

Certificate of Competency(CH. Eng)        
Certificate of Competency(MTM)        
Oil Tanker Endorsement        
Chemical Tanker Endorsement        
Gas Tanker Endorsement        
Oil Tanker Familiarization Training        
Chemical Tanker Familiarization Training        
Gas Tanker Familiarization Training        
Oil Tankers Specialized Training        
Chemical Tanker Specialized Training        
Gas Tanker Specialized Training        
Basic Trainings        
Proficiency in Survival Craft and Rescue Boats         
Advanced Fire Fighting        
Medical First Aid Training        
Medical First Aid Training and Medical Care        
GMDSS        
GMDSS Endorsement        
Radar Observation & Plotting        
Automatic Radar Plotting Aids Simulator (ARPA)        
Bridge Team Management        
Shiphandling & Maneuvering        
Ship Security Officer Training Course        
Maltese Endorsement of SSO        
ELECTRICAL ELECTRONIK AND CONTROLE ENGINEERING        
DESIGNATED DUTIES        
SECURUTY AWARENESS        
Risk Assessment Course        
C. O. W. / I. G. S        
Fire Practice on Tankers        
Vapour Recovery System        
Unmanned Machinery Space        
FRAMO Familiarization Course        
Cargo Ballast Operations on Oil/Chemical Tankers        
Hazardous Materials        
Welder        
Turner        

 

8. Physical Data

Height  
Weight  
Colour of Hair  
Colour of Eyes  
Boilersuit Size  
Shoes Size  

 

9. Medical History Yes No
Have you ever signed off a ship due to medical reasons?    
Did you undergo any medical operation in the past?    
Have you consulted a doctor during the last 12 months for an illness/accident?    
Do you have any health or disability problems now?    

 

If yes, please give full details:    

 

  Passed: Valid till:
International Medical Examination    
Vaccination Against Yellow Fiver    
Vaccination Against Diphtheria    
     

 

10. References (please give name and address of your current or past employer) Office remarks

 

Name of Company    
Name of person to contact    
Address    
Phone    

 

Name of Company    
Name of person to contact    
Address    
Phone    

 

11. Bank address for allotments

Beneficiary  
Account No.  
Name of Bank  
Bank Address  

 

12. Knowledge and experience Yes No
OCIMF vetting experience:    
ISGOT knowledge:    

 

13. I hereby declare that the above, including Medical History, is true

Place                   Date  Signature 

 

14. For Office use only    
 


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