Amadey Maritime and Crewing Agency

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Application form

AMADEY MARITIME AGENCY

Fax: +38 048-731-75-98 Tel: +38 048-731-75-96 +38 048 716554

E-mail: crew@amadey-odessa.com

"DOWNLOAD APPLICATION FORM in EXEL format

Position applied for:

Second choice:

Minimum salary:

Ready from:

CODE No:

Surname:

Name:

Patronymic

Date of birth:

Citizenship:

Tel:

Mobile:

Address:

E-mail:

Weight:

Height:

Color of eyes:

Color of hair:

Marital status:

Number of children under 18:

Next of kin name and relation:

Contact No:

USA visa No:

Expire date:

SCHENGEN visa Yes/No:

Expire date:

PASSPORT AND SEAMANS BOOK FOREIGN					LICENSE AND ENDORSEMENT INCLUDING FOREIGN
	Number	Issued	Valid	Place of Issue	License / Endorsement	Number	Issued	Valid	Place of Issue
International passport :
Seaman's Book :					Endorsment
Other :

STCW 95 CERTIFICATES
	Number	Valid	Place of issue		Number	Valid	Place of issue
Survival at sea VI/1				Chemical and Liquefied Gas Tankers A-V/1
Advanced fire fight A-VI/3				Oil Tanker Safety A-V/1
Medical care / First aid A-VI/4				RO-RO Passenger Ship
Proficiency in survival craft A-VI/2				RO-RO Ship
Danger and hazard cargoes B-V/4&B-V/5				Maintenance of electrical (for I,II eng.) A - III/2
RADAR (DECK OFF.) AII/I.AII/2,BI/12				Ships Safety officer IMO A.741(18)
ARPA (DECK OFF.) AII/I.AII/2,BI/12				Ships Security Officer
GMDSS (D/officer) Endorsement IV/2				Last medical / drug test
Refresher & Updating I/11				Yellow fever vaccination:

PREVIOUS SEA SERVICE(LAST 5 YEARS)
Name of vessel	Flag	Type of vessel	DWT	Main Engine	BHP	Rank Rating	From d/m/y	To d/m/y	Owner or Operator

EDUCATION INFORMATION
Marine academy/school attended	Address	From	To	Degree obtained

PREVIOUS CREWING COMPANIES DETAILS			Индификационный код No
COMPANY	ADDRESS	TEL / E-MAIL	ПАСПОРТ ГРАЖДАНИНА УКРАИНЫ
			Ф.И.О
			Серия и No
			Дата, кем выдан

Please complete address of Your previous employers for references
Company:		Company:
Address:		Address:
Tel/Fax		Tel/Fax
E-mail:		E-mail:

If you have Curriculum Vitae or any references, please attach. Filling out this application form does not guarantee employment I understand that my working contract will be canceled without nitrifying if any of submitted information and documents is voted as false.
Date :		Signatures :

For"AMADEY" maritime agency use only.
		Excellent	Good	Satisfactory	Poor	Last salary: USD
Spoken English	Common					Willing to accept low rank?
Spoken English	Professional					Experience with foreign crew:
Computer test:	CES 4.1
Computer test:	Marlins
Previous reference -"FIT?"			Vessel :			Computer user:
Previous reference -"FIT?"			Rank :			Leadership:

Other sea and shore experiences:
Interviewed by: Capt.Dmytriy Yemelyanov
Final remarks:

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