APPLICATION FOR SEAGOING APPOINTMENT
All dates must be entered in day/month/year order!
Fields with this color are required

Old version of application (Microsoft Word file)
1. PERSONAL INFORMATION
RANK ALTERNATIVE RANK (IF ANY)
SURNAME FIRST NAME
OTHER NAMES NATIONALITY
PESEL MARITAL STATUS
MOUSTACHEYes No BEARDYes No
BIRTH PLACE DATE OF BIRTH (dd/mm/yyyy)
COLOUR OF EYES COLOUR OF HAIR
MOTHER'S NAME FATHER'S NAME
HEIGHT (CM) WEIGHT (KG)
INTERNATIONAL AIRPORT (NEAREST TO HOME TOWN)

2. ADDRESS (PERMANENT) ADDRESS (TEMP.) FROM/TO (dd/mm/yyyy):
STREET STREET
POST CODE POST CODE
CITY CITY
COUNTRY COUNTRY
TEL. NO. TEL. NO.
MOBILE MOBILE
E-MAIL E-MAIL
FAX FAX

3. NEXT OF KIN
FULL NAME RELATION
ADDRESS
POST CODE CITY COUNTRY
TEL. NO. MOBILE PHONE NO. FAX NO.

4. DETAILS OF CHILDREN
NAME OF CHILDDATE OF BIRTH

(dd/mm/yyyy)


5. TRAVEL DOCUMENTS
DOC./VISA TYPE DOC./VISA NO. ISS.DATE

(dd/mm/yyyy)

 EXP. DATE

(dd/mm/yyyy)

 PLACE OF ISSUE
PASSPORT
SEAMAN BOOK
US C1/D VISA

6. BANK ACCOUNT INFORMATION (OPTIONAL)
BANK NAME BRANCH
STREET
POST CODE CITY
ACCOUNT NO SWIFT/BIC CODE
HOLDER OF BANKACCOUNT

7. EDUCATION
SCHOOL NAME FROM (year) TO (year)

8. LICENCE AND COURSE INFORMATION
LICENCE NAME NUMBER ISSUE DATE

(dd/mm/yyyy)

 EXPIRY DATE

(dd/mm/yyyy)

 ISSUED AT
COURSE NAME NUMBER ISSUE DATE

(dd/mm/yyyy)

 EXPIRY DATE

(dd/mm/yyyy)

 ISSUED AT
BASIC SAFETY TRAINIG
PERSONAL SURVIVAL
BASIC FIRE FIGHTING
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID
MEDICAL FIRST AID
MEDICAL CARE
PERS. SAFETY AND SOC. RESP.
PROF. IN SURVIVAL CRAFT
FAST RESCUE BOATS
OIL TANKER FAMIL.
CHEMICAL TANKER FAMIL.
LPG TANKER FAMIL.
ADV. OIL TANKER OPER.
PERMISSION ON OIL TANK.
ADV. CHEM. TANKER OPER.
PERMISSION ON CHEM TANK.
ADV. LPG TANKER OPER.
PERMISSION ON LPG TANK.
GMDSS
RADAR OBSERVER
ARPA
HAZMAT
HEALTH CERTIFICATE
YELLOW FEVER
DRUG AND ALCO TEST

9. ENGLISH PROFFICIENCY
Fluent Very good Good Fair Poor

10. SEAFARER'S SAILING RECORD
VESSEL NAME SHIP OWNER VESSEL TYPE VESSEL FLAG G.R.T. ENGINE TYPE KW RANK SIGNED ON

(dd/mm/yyyy)

 SIGNED OFF

(dd/mm/yyyy)


11. REFERENCES
COMPANY NAME
ADDRESS
PHONE NO.
FAX/E-MAIL
CONTACT PERSON

Niniejszym wyrażam zgodę na przetwarzanie moich danych osobowych dla potrzeb działalności pośrednictwa pracy, prowadzonej przez Norspol Sp. z o.o. z siedzibą w Warszawie, zgodnie z Ustawą o Ochronie Danych Osobowych, w tym na udostepnianie tych danych podmiotom zagranicznym (potencjalnym pracodawcom).