Deck department officers

Photo 3x4

Possition applied for
Master Chief Officer 2nd Officer 3rd Officer Junior Officer Deck Officer Trainee

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

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

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

4.Place of Birth

Telephone Number

Email

5.Marital Status
MarriedSingleDivorcedWidow/Widower

6.Citizenship

7.Complete Address
«Street Name, Building No, Appartment No, City, ZIP Code, Country»

a) Relationship

b) Family Name

c) First Name

Email

Place of Residence
«Street Name, Building No, Appartment No, City, ZIP Code, Country»

a) Height

b) Weight

c) Boot Size

d) Overall Size

e) Color of Eyes

f) Color of Hair

Educational Institution
CoursesSchoolCollegeAcademy

Specialty

Place

Period of Studies

From

To

Certificates of Competency

Certificate of Competence:

Grade

Number

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Country

Endorsement:

Grade

Number

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Country

Basic Safety Course (VI/1)

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Advanced Fire Fighting (VI/3)

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

br

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

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

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

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

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

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Tankerman Oil

 Familiarization Advanced

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Tankerman Chemical

 Familiarization Advanced

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Tankerman Gas

 Familiarization Advanced

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Radar Observation & Plotting Simulator Course

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Automatic Radar Plotting Aids(ARPA)

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

GMDSS General Operator

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Bridge Team & Resource Management

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Maneuvering & Ship Handling

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

ECDIS

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

SSO (Ship Security Officer)

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Safety Officer

Number

Country

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Passports and Visas

Tourist / Travel Passport

Country

Serial Number

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Seaman's Book / Seaman’s Passport

Country

Serial Number

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

US Visa C1/D

Country

Serial Number

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Medical Certificate and Vaccination

Medical Certificate

Date of Issue (DD.MM.YYYY)

Date of Expire (DD.MM.YYYY)

Yellow Fever Vaccination

Date of Issue (DD.MM.YYYY)

Tests

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.YYYY)

Sign-off (DD.MM.YYYY)

2.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

3.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

4.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

5.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

6.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

7.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

8.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

Archive with the originals of all documents

9.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

10.

Owners or Managers

Vessel's name

Type of vessel

Flag

GRT

Kwt

Type of Engine

Rank

Sign-on (DD.MM.YYYY)

Sign-off (DD.MM.YYYY)

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.