Fratelli dAmico Armatori S.p.A.

ROMA
Rev. 0

Crew Application Form

Date 23/08/10

IP 03 Form 02a
Pag. 1

[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM] Individuals Code Number

1. Personal Data
First Name Carpov Middle Name (s)

marian

Last Name / Surname aurel

AFFIX YOUR RECENT PHOTOGRAPH HERE (PASSPORT SIZE)

Nationality (or current Citizenship ) roumanian Marital Status1: Married

Country of Origin roumania

Date of Birth: 31 / 05 / 1982

(DD / MM / YY)

Place / City of Birth tulcea

Religion: Gender : Male ortodox Female 1 Select from : Single Married Divorced Common Law Partner Widowed Separated Rank applied for: 3 eng Primary / Permanent Address: Willing to accept lower rank? Yes No Available From (date): __ / __ / __
(DD / MM / YY)

Aleea garofitei,nr.10,bl.l 77, sc. A ,apt.8 et.3

Alternative / Temporary Address:

Until:

__ / __ / __
(DD / MM / YY)

City: constanta State:roumania Nearest Airport otopeni Mobile Tel. 0730396722 Contact Method : Collar: ______cm Email

Post Code: Country : Home Tel: 0341171577 Fax: Fax

City: State: Phone: Email: Mobile Phone Home Phone

Post Code: Country:

Post Cap: ______cm Shoe size:45

Chest: ______cm

Waist: ______cm Sweater size:

Inside Leg: ______cm Boilersuit size: xl

Specify size as S, M, L, XL, XXL for :

2.

Personal ID / Documents / Visa

Type of Document / ID 1 Seamans Book (National) Passport US Visa C1/D National Seaman ID Yellow fever Australia MCV Country of Issue romania romania romania romania romania 10.11.2006 constanta 10.11.2016 20545ct 50669122 98887711 No. Date of Issue (DD / MM / YY) 16.09.2008 21.05.2011 20.11.2008 Issued at (Place) constanta constanta bucharest Valid Until (DD / MM / YY) 14.04.2012 21.05.2016 18.11.2013

GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO

Social Security
Number: Issuing Country: Number:

Personal Tax (or Fiscal Code)

Issuing Country:

Fratelli dAmico Armatori S.p.A. ROMA

Rev. 0

Crew Application Form

Date 23/08/10

IP 03 Form 02a
Pag. 2

3.
Next of Kin & Family Details
Full Name of Nominee for compensation in case of fatality: Carpov laura elena Address:str.aleea garofitei, nr.10 City:constanta Email:
1

Nominee
Relationship1 wife Post Code: Tel:0341171577 Gender : Male Female Nationality :roumanian

Country: Mobile:

Select From : Spouse Partner Child Parent Grand Parent Other Relative (Please Specify)

Family Data:
Relationship Spouse / Partner Child Child Child Child Child
2 2

First Name F F F F F USA

3

Last Name

Date of Birth

Place

Fiscal Code

M M M M M

Indicate type of valid visa3 Strike out inapplicable item

Canada

Australia

Schengen

UK

Other: __________________________

Please consider period on board

4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: (Add separate sheet if data exceeds space available.) Description of Cert / Course (A) Reg I Personal Training Record Reg I/14 Medical Fitness Cert Reg I/9 (B) Reg VI / 1 Basic Safety Training Personal Survival Techniques romania Elementary/Medical First Aid Fire Fighting & Fire Prevention Personal Safety & Social Resp. (C) Reg VI / 2 4 Additional Training Prof. in Survival Craft & Rescue Boat Fast Rescue Boats Advanced Fire Fighting Medical Care (Master / C/O) romania 12394 21.07.2010 21.07.2015 constanta ceronav 13121 14.07.2010 14.07.2015 constanta ceronav Country of Issue Number Date of Issue (dd-mmyy) Date of Expiry (dd-mmyy) Place of Issue Issuing Authority / Body

12361

26.07.2010

26.07.2015

Constanta

ceronav

(D)
4

Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag state endorsements)

Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you Other mandatory/recommended Certificates / Courses (as applicable) Radar Simulator (Basic) ARPA (Reg II/1 + Solas) English Language Test/Course Bridge Team / Resource Mgmnt

(E)

Select as applicable: Passport Seamans Book Seaman Passport Seafarers Identity Document Registration Book National ID Card PAG-IBIG Housing Insurance Health Insurance Overseas Emp Cert PHL Card Pension Fund Provident Trust Professional Organisation Driving Licence Visa Vaccination Yellow Fever.

Fratelli dAmico Armatori S.p.A. ROMA

Rev. 0 Hazmat (US 49CFR) Shiphandling Simulator Ship Security Officer (SSO) ECDIS ARPA SAR (Master / C/O)

Crew Application Form

Date 23/08/10

IP 03 Form 02a
Pag. 3

Description of Cert / Course

Country of Issue

Number

Date of Issue (dd-mm-yy)

Date of Expiry (dd-mm-yy)

Place of Issue

Issuing Authority / Body

(F)

GMDSS Certificates (including flag state endorsements) GMDSS (Main Issuing Authority) Endors. GMDSS (Flag State)

(G)

Reg V / 1 Special Requirement for Tankers Country Level1:Asst Description Number Level2:Incharge of Issue Endorsement Oil Endorsement Chem I/II Endorsement Chem III Endorsement Gas Tanker Familiarisation Tanker Safety Tanker Safety Tanker Safety (Oil) (Gas) Para 1 Para 2 Para 2 13455 12549 13268

Date of Issue (dd-mm10.11.2008 01.06.2009

Date of Expiry (dd-mm07.11.2013 26.05.2014

Place of Issue constanta constanta

Issuing Authority / Body anr anr

10.11.2008

08.10.2012

constanta

anr

(Chemical) Para 2

V/2 and V/3 Other special training For Vsl Country of Description Type (1) Issue Crisis Mgmnt & Human Behaviour Cargo Handling & Hull Integrity Crew Safety Training Environment Protection Training Risk Assessment Incident Investigation

(H)

Number

Date of Issue (dd-mm-yy)

Place of Issue

Issuing Authority / Body

5. Sea Experience : (Last 5 years; Start the listing below with the most recent experience)
Company Flag & Vessel Name Type
(1)

GRT

DWT

Main Engine

(2)

BHP

Rank

Date From dd/mm/yy

Date To dd/mm/yy

capital capital V SHIPS V SHIPS BARKLAV

LIBERIA/AGAMEMNONi TNP i MILTIADISMii/LIBERIA PORT UNION PORT UNION ELISEWIN/LIBERIA TNC TNP TNP TNC

30010 87146 29998 29998 78845

51000 162000 46256 46256 149991

MAN B &W MAN B &W MAN B&W MAN B&W SULZER

12900 29540 11870 11870 16440

3 ENG 06.06.2011 07.10.2011 3 ENG 21.08.2010 06.01.2011 3 ENG 30.04.2010 27.06.2010 3 ENG 22.06.2009 25.11.2009 4 ENG 01.12.2008 22.04.2009

Fratelli dAmico Armatori S.p.A. ROMA

Rev. 0

Crew Application Form

Date 23/08/10

IP 03 Form 02a
Pag. 4

(1)

Use only the following abbreviations for vsl types:

BC CON CH M CH3 FSV

(2)

Bulk Carrier Cellular Container Chem Carrier IMO I-II Chem Carrier IMO III Fishing Vessel

FSO FPS O LNG LPG NVL

FloatingStorage Offldg FloatgProdStor Offldg LNG Carrier LPG Carrier Naval Ship

OB O OS V OT H PA S PR R

Ore/Bulk/OilCarr ier OffShore Supply Vsl Other Passenger Ship RoRo-Pax

RIG RF G R/R SR V TU G

OffShore Oil Rig Reefer Vessel Ro/Ro Carrier Survey Vessel Tug

TNB TNC TNP TNS TNV

Tanker(Bitume n) Tanker(Crude) Tanker(Produc ts) Tanker(Storag e) Tanker(VLCC/ULC C)

Engineers to give make/model of engines, e.g. MAN 14V52/55A; SULZER 5RTA58; etc.

Fratelli dAmico Armatori S.p.A. ROMA

Rev. 0

Crew Application Form

Date 23/08/10

IP 03 Form 02a
Pag. 5

6. Medical History:
All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed, the Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured benefits. (A) Have you ever signed off a ship due to medical reasons? Yes No If yes, please provide following details (If space is insufficient, attach additional sheets) :
Name of vessel Brief description of illness/injury/accident: Date of occurrence Place of occurrence

(B) Have you undergone any operation or special medical treatment in the past? If yes, please provide following details:
Details of operation Date Period of disability

Yes

No

Present condition

(C) For what illnesses or accidents have you consulted a doctor during the last 12 months?
Details of illness / accident Date Therapy/Treatment

(D) Please give details of any health or disability problem (including also eventual allergies)
Details:

7. Bank Details:
Bank Name Address Account Name Account No. Sort Code

Other Details: (if any)

8. General
(A) Have you ever been denied a foreign visa? Yes No If yes, state which country and reason (if known) (B) Have you been the subject of a court of enquiry or involved in a maritime accident? If yes, please attach details (C) Give details below of two recent employers who we may contact for references:
Reference 1 Name of Company Name of person to contact Address

Yes

No

Reference 2

Country Telephone I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by your Company of personal data about me (including where appropriate data concerning racial or ethnic origin, religious beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an offence and the proceedings and the outcome of any proceedings relating thereto) for all purposes related to my application for employment on board vessels Owned and managed by the Company. I understand that this data will be stored in your databases in relation to my actual or potential employment.

Place: ............. Date: 08.11.2011

Signature: .CARPOV..

Fratelli dAmico Armatori S.p.A. ROMA

Rev. 0

Crew Application Form

Date 23/08/10

IP 03 Form 02a
Pag. 6

FOR OFFICE USE ONLY: Privacy Requirements.

All informations listed in the present form will be used in compliance with