CMA SHIPS REF: CREW/FORM/01 TITLE:

CREWING MANUAL VERSION: 02/08/2010

APPLICATION FORM

APPENDIX 2 PAGE 1 of 1

APPLICATION FORM
ATTACH CMA Ships ROMANIA 2nd Floor, 13-15 Mamaia Boulevard, CONSTANTA C.P. 900697 Tel: +40 241610778 / +40 241610779 E-mail: cnz.crew@cmaships.com

Position applied for: Type of vessel: Availabibity date:

Are you responding to a media advertisement? If YES, please state which one Are you applying upon personal or professional recommendation? If YES, please state who Surname: Other names Place of birth: Known as Date of Birth:

YES/NO

YES/NO

First name: Nationality: Age: Male Female

Passport
Number Place of issue Date of issue Date of expiry Issuing Authority

Visas
Type C1/D (USA) C1 (USA) D (USA) Australia Entry visa MCV (Australia) Schengen Number Place of issue Date of issue Date of expiry

Education Background
School / College From To Highest qualification attained

Personal details
Full address: Postal code: E-mail: Home tel number: Mobile phone: Domestic Airport Marital status: International Airport Country:

Full name of Next of Kin: Address of Next of Kin if different from above Phone if different from above

Relationship

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Dependents
Name Date of birth Age Gender Relationship

Person to contact in case of emergency

Name: Address: Phone number: Mobile number: Relationship

National Seaman's Book

Number Place of issue Date of issue Date of expiry Issuing Authority

National Certificate of Competency (COC)- Licences

Grade Issuing Authority Number Date of issue Date of expiry Place of Issue Date revalidated Date expiry

National GMDSS & Endorsement

Issuing Authority Number Date of issue Date of expiry Place of Issue

Medical Fitness Certificate

Type Date of issue Date of Expiry

Yellow Fever Vaccination

Date of Issue Date of Expiry

Foreign languages other than English

Language Level: Beginner Intermediate Advanced

Medical History
Have you ever signed off from a ship due to medical reasons? Name of vessel Yes / No Date of Occurrence If yes give details

Brief description of Illness or Injury

Other personal details

Height: Colour of eyes: Uniform Shirt size: Weight: Safety shoes size: Uniform Trousers size: Colour of Hair: Boiler suit size:

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Details of other Marine courses

Type of Marine Course Basic Training Personal Survival Techniques Basic Fire Fighting Elementary First Aid
Personal Safety & Social Responsibilities (Human Relationship)

IMO model course

1.19 - 1.20 1.13 1.21

Reference- Regulation STCW Reg. VI/1-1 to A-VI/1-4 STCW Reg. A-VI/1-1 STCW Reg A-VI/1-2 STCW Reg A-VI/1-3 STCW Reg A-VI/1-4 A-

Number

Date of issue

Date of expiry

BASIC TRAINING

1.19 1.20 1.13 1.21 1.23 2.03 1.14 1.15 1.08 1.07

Proficiency in survival craft & Rescue Boats

STCW Reg A-VI/2 par 1.3 STCW Reg A-VI/3 STCW Reg A-VI/4-1 STCW Reg A-VI/4-2 par 2 STCW Reg II/2 STCW Reg II/1

Advanced Fire Fighting Medical First Aid Medical Care ROP ARPA / NCC Radar Simulator ECDIS HAZ MAT Ship simulator bridge teamwork BTM / ETM Ship Security Officer (SSO) BASSnet Ship handling & manoeuvring Bridge resource management Loading software (name it)
Large Vessel Handling Simulator / Engine Room Simulator

1.27

STCW Reg II/1 par.2.5 US 49 CFR 172.700-172.204

1.22

STCW Reg II/1

STCW Reg VI/5 / ISPS Code

STCW Reg II/1 & II/2 STCW Reg VIII/2 US33CFR 157.415

CMA CGM

Indos Number Upgradation Course Revalidation Course for renewal of CoC High Voltage Training Reefer Training Engine Makers Training Crane Manufactures training Vessel security training course Ship Safety Officer ISF Marlins English test MARPOL ISPS code IMO Assembly Res A741(18) UK MCA

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Flag State Documents

Document Grade Number Place of Issue Date of Issue Date Expiry

Malta:
Seafarer's Book Endorsement of the GMDSS Endorsement of the CoC

Cyprus :
Seafarer's ID and Sea Service Record Book Cert. Of Recognition of the National CoC

Bahamas:
Endorsement of the CoC Endorsement of the GMDSS Seafarer's Identification and Record Book

United Kingdom:
Endorsement of the CoC (UK CeC) Endorsement of the GMDSS Seafarer's Identification and Record Book

Panama:
Endorsement of the CoC Endorsement of the GMDSS GOC Seafarer's Identification and Record Book

Other ( pls specify)

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Employment history (at least the last 5 years)

Vessel * Company Manning Agent Trading area Vesse l type Flag DWT / TEU Year built Main Engine
Make Type KW

Position

Sign on date

Sign off date

Total mm/dd

**

Reaso n for leaving

***

* or industry sector if ashore

** Use abbreviation: PC = Pure container, GC = General Cargo, BC = Bulk Carrier, LNG = Tanker, LPG = Tanker, Chem = Chemical, RoRo = Roll on Roll off *** Use abbreviation: MR = Medical Reason, VS = Vessel Sold, EOC = End of Contract

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Summary of Experiences (in number of years)

Years as/ on Master - C/E C/O - 2/E 2/O - 3/E 3/O - 4/E E/O Total Years as/ on C/E 2/E 3/E 4/E E/O Total SEMT Pielstick Steam Turbine Container Tanker Bulk carrier Roro others (Please state)

Sulzer RTA

Sulzer RND

B&W

MAN

others

References
Do you have any objection if we will contact your last employers for reference? If YES please specify why: If NO please specify below: Yes/No

Please give the name and address of your current or immediate past employer
Name of company Name of person to contact Address

Tel number

Please list two contactable referees or past employers

Name of company Name of person to contact Address

Tel number Name of company Name of person to contact Address

Tel number

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Bank details
Bank name: Branch name Address: Account name/ Title Account number: Swift name IBAN number: Sort code:

I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief; further, that no Certificate of Competency or License issued to me has ever been revoked or suspended. I also certify that my medical history contained abocve is true and any false statement or undisclosed material information about past illness or injury will disqualify me from any employment benefits and claims.

Date________________

Signature_______________________

* The company may contact my previous employer for references.

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