Application

Photo 3x4

1.Possition applied for

2.Family Name (as in Seamen's Book)

3.First Name (as in Seamen's Book)

4.Date of Birth (DD.MM.YYYY)

5.Place of Birth

6.Complete Address

Telephone Number

Email

7.Marital Status
MarriedSingleDivorcedWidow/Widower

8.Citizenship

Next of Kin

a) Relationship

b) Family Name

c) First Name

d) Place of Residence

Email

Other Personal Data

a) Height

b) Weight

c) Boot Size

d) Overall Size

e) Color of Eyes

f) Color of Hair

Maritime Education

Educational Institution
CoursesSchoolCollegeAcademy

Specialty

Place

Period of Studies

From

To

Certificates of Competency

Certificate of Competence:

Grade

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Endorsement:

Grade

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Basic Safety Course (VI/1)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Advanced Fire Fighting (VI/3)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

br

 Medical First Aid (VI/4-1) Medical Care (VI/4-2)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Survival Craft and Rescue boats (VI/2-1)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Proficiency in Fast Rescue Boats (VI/2-2)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Tankerman Oil

 Familiarization Advanced

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Tankerman Chemical

 Familiarization Advanced

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Tankerman Gas

 Familiarization Advanced

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Radar Observation & Plotting Simulator Course

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Automatic Radar Plotting Aids(ARPA)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

GMDSS General Operator

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Bridge Team & Resource Management

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Maneuvering & Ship Handling

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Welder

 Electro GAS TIG

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

ECDIS

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

SSO (Ship Security Officer)

Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Country

Passports and Visas

National Passport

Country

Serial Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Tourist / Travel Passport

Country

Serial Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Seaman's Book / Seaman’s Passport

Country

Serial Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Other Seaman’s Book

Country

Serial Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Other Seaman’s Book

Country

Serial Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

US Visa C1/D

Country

Serial Number

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Medical Certificate and Vaccination

Medical Certificate

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Drug & Alco Test Certificate

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Yellow Fever Vaccination

Date of Issue (DD.MM.YY)

Date of Expire (DD.MM.YY)

Tests

MARLINS test result

Percent

Date

CES 4.1 test result

Percent

Date

Previous Sea Service

Please submit the complete information about your service at sea during last five years

1.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

2.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

3.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

4.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

5.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

6.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

7.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on(DD.MM.YY)

Sign-off(DD.MM.YY)

Archive with the originals of all documents

DECLARATION: I do hereby declare that all the above statements are complete and correct to the best of my knowledge. I do understand that this application form contains information vital for my further employment, however, its presenting gives me no guarantee for such unless proper requirement available. I do also understand that the below assessments of my qualifications and knowledge will affect my ability to be employed via LAPA Ltd.

WHILE SUBMITTING YOUR APPLICATION

• Please attach: the originals of all the documents you have indicated above, all of your passports, your medical book, and your vaccination book.
• Have your tests passed.
Your application will not be accepted unless it complies with all the above requirements.