MPM C-002 — Application Form

Position Applied For & Availability

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Position

Personal Reference Number

Available from

If applicable, lower rank acceptable?

Yes No

Personal

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First name

Middle name

Last name

Date of birth

Place of birth

Nationality

Country of residence

Gender

Male Female

Passport picture

No file selected

JPG or PNG, max 8 MB. Recent, head-and-shoulders, neutral background.

Marital status

Single Common Law Partner Married Separated Divorced Widow(er)

Blood type

Social Security No

Issuing country (SSN)

Personal Tax No (optional)

Issuing country (Tax)

Provide tax information only if requested at the time of employment.

Address

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Permanent — Address line 1

Permanent — Address line 2

Permanent — City

Permanent — Post code

Permanent — State

Permanent — Country

Temporary — valid until

Temporary — Address line 1

Temporary — Address line 2

Temporary — City

Temporary — Post code

Temporary — State

Temporary — Country

Nearest airport

Mobile no.

Home phone

E-mail address

Working Gear

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In centimetres

Collar

Chest

Waist

Inside leg

In sizes (S / M / L / XL / XXL)

Cap / Hard hat

Sweater

Boiler suit

Shoe

Identity & Travel Documents

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Document	Number	Country of issue	Place of issue	Date of issue	Valid till

Visa

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US Visa C1/D

Schengen

Australia MCV

Other visa

Bank Details

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Account name

Account no.

Account currency

Bank name

Bank address

SEPA / SWIFT

Health

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Yellow Fever — date

Other immunisations

Name	Date

Certification — STCW Reg I

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Cert / Course description	Number	Country of issue	Issuing authority / body	Place of issue	Date of issue	Valid till
Personal Training Record Reg I/4
Medical Fitness Certificate Reg I/9
Personal Survival Techniques
Elementary First Aid
Fire Fighting & Fire Prevention
Personal Safety & Social Responsibility
Proficiency in Survival Craft & RB
Fast Rescue Boats
Advanced Fire Fighting
Medical First Aid
Medical Care — Master / Chief Mate

Competency / Watchkeeping Certificates

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Cert / Course description	Number	Country of issue	Issuing authority / body	Date of issue	Valid till
ARPA (Reg II/1 & SOLAS)
Radar Simulator
English Language
Bridge Team & Resource Mgt.
Hazmat (US — 49CFR)
Shiphandling / ShipMan Simulator
Shipboard Security Officer
ECDIS
BOSIET
HUET
GMDSS — Main Issuing Authority

GMDSS — Flag State

Country of issue	Number	Date of issue	Valid till

Tanker Endorsements

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Tick below if In Charge of a Watch or Assistant

	Number	Country of issue	Date of issue	Valid till
Endorsement — Oil
Endorsement — Chem. I/II
Endorsement — Chem. III
Endorsement — Gas
Tanker Familiarisation — Oil
Tanker Familiarisation — Chem.
Tanker Familiarisation — Gas
Special Tanker Safety — Oil
Special Tanker Safety — Chem.
Special Tanker Safety — Gas

Passenger / Ro-Ro Passenger Vessels

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Tick below if Passenger or Ro-Ro Passenger vessels

	Number	Country of issue	Date of issue	Valid till
Crowd Management
Crisis Management & Human Behaviour
Passenger / Cargo Safety + Hull Integrity
Familiarisation Training
Safety Training

Sea Service Experience (start with most recent)

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Company	Vessel flag	Vessel name	Type	GRT	DWT	Main engine	kW	Rank	From	To

Declarations concerning Medical History

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I have previously signed off for:

Type	Vessel	Name	Place	Date	Details

I have had the following surgeries:

Name of surgical intervention	Date of surgery	Period of disability	Present condition

I have consulted a doctor during the last 12 months for the following illnesses or accidents:

Name of illness / accident	Date of consultation	Therapy / Treatment

Declaration of Nominees (in case of death)

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First name

Middle name

Last name

Gender

Male Female

Relationship

Spouse Partner Child Parent Other (specify)

Nationality

Mobile tel.

E-mail

Address — city

Address — post code

Address — country

Family Information

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Relationship	First / Last name	Date of birth	Passport no. / Place of issue	Date of issue	Valid till

Other Declarations

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I have NOT been denied a foreign visa. I HAVE been denied a foreign visa (please describe below).

Details — visa denial

I have NOT been involved in any maritime accident. I HAVE been involved in maritime accident(s) (please describe below).

Details — maritime accident

Recent References we may contact

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Contact person	Telephone no.	Company name & address (preferably with e-mail)

Consent & Signature

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I hereby declare that the above facts and information are true and accurate. I consent to the holding and processing by (i) the owners of any vessel to which I may be assigned from time to time and (ii) the Managers and any direct and indirect parent, subsidiary or associated company of the Managers (together referred to as "the Companies") for the purpose of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date — including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers' database for the purpose of my current employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers' organisation.

I have read and agree to the declaration above.

Place

Date

Applicant's signature (type full name)