epsilon Odessa

11, Italian Bulevard, Odessa 65012, Ukraine

Tel : 00380 487280062 E-mail: anketa@epsilonodessa.com.ua
Tel : 380,321,253 Web: http://www.epsilonodessa.com.ua
Fax : 380,321,484
A. SEAMAN'S PERSONAL DETAILS
Position to Apply for
Certificate of Competency Rank min wage
Name Surname
Father's name Mother's name
Date of Birth Place of Birth Last wage
Address
Phones
YES YES How many
Marital Status Married Children Number under 18 years
NO NO old ?

Names and age of children

Next of kin Relation
Address
Date of Issue
Seaman's Book. No. Place of issue
Date of validity

Date of Issue
Tourist Pass. No. Place of issue Date of validity

Civil Pass. No. Date of Issue Date of validity

English Ability FLUENT VERY GOOD GOOD FAIR

Distinctive Marks Height (cm): Weight (kg):

B. DOCUMENTATION
DOCUMENTS Number Date of Issue Date of Validity Place of Issue
CERT. OF COMPETENCY
ENDORSEMENT OF CERT.
F.F.T. (НБЖС)
SURVIVAL CRAFT
RADAR (DECK OFF)
ARPA (DECK OFF)
GMDSS (DECK OFF)
FIRST MEDICAL AID
ADV.MEDICAL CARE
ADV.FIRE FIGHTING
DANGEROUS CARGOES
SHIP`S SAFETY OFFICER
SHIP SECURITY OFFICER
TANKERMAN CERTIFICATE
OIL TANKER SAFETY
CRUDE OIL WASHING
CHEMICAL TANKER SAFETY
RO-RO PASS. SERTIFICATE

YELLOW FEVER
USA VISA VALID UNTILL: YES NO
C. PREVIOUS SEA SERVICE
VESSEL TYPE DW ENG HP RANK S/ON S/OFF OWNERS CREWING
SIGNATURE_____________ DATE:_______________________