POLMARINE SERVICES Ltd.

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APPLICATION FOR SEA STAFF EMPLOYMENT

ZŁOŻONA APLIKACJA NIE PODLEGA ZWROTOWI! APPLICATION FOR SEA STAFF EMPLOYMENT
PHOTO	POLMARINE SERVICES SP. Z O.O. 38/5 WASZYNGTONA STR., GDYNIA PH: 48 58 661 25 00, 661 25 03, 621 99 45 FAX: 48 58 621 95 15 E-MAIL: pms@polmarine.com.pl

RANK		READY TO WORK FROM
SURNAME		FIRST NAME
DATE OF BIRTH		PLACE OF BIRTH
FATHER_NAME		MOTHER NAME
ADDRESS.
PHONE		EMAIL
NEXT OF KIN
ADDRESS & PHONE
PASSPORT NO.		VALID
PASSPORT PLACE OF ISSUE		PASSPORT DATE OF ISSUE
SEAMAN'S BOOK NO.		DATE & PLACE OF ISSUE

POLISH LICENCE		NO		VALID
OTHER LICENCE: BAHAMA, PANAMA, CAYMAN, ISLANDS, ISLE OF MAN, ST. VINCENT
NUMBER & VALIDITY
USA VISA NO

LANGUAGES		V.GOOD	GOOD	MODERATE	POOR
LANGUAGES
PREVIOUS POLISH COMPANY

	FOREIGN FLAG EXPERIENCE
Lp.	COMPANY	NAME OF THE VESSEL	FLAG	TYPE OF THE VESSEL	GRT
1
2
3
4
5

	FOREIGN FLAG EXPERIENCE
Lp.	TYPE OF ENGINE	ENGINE POWER	RANK	FROM	TO	NAME OF THE AGENCY
1
2
3
4
5

	CERTIFICATES
Lp.	NAME	BASIC OR ADVANCE	VALID/ISSUE	NO	PMS INFO
1	FIRE FIGHTING
2	ITR
3	MEDICAL COURSE
4	PERSONAL SAFETY
5	GMDSS
6	ARPA
7	RADAR OBSERVER
8	PERSONAL SURVIVAL CRAFT
9	CHEM./ OIL TANKER /GAS FAMILIARISATION
10	PRACTICAL SHIP HANDLING LARGE VESSEL

	HEALTH CERTIFICATE
VALID
	DRUG &ALCOHOL TEST
ISSUED
	ADDITIONAL INFORMATION

	Zgodnie z ustawą z 29.08.97 "O ochronie danych osobowych" wyrażam zgodę na przechowywanie i przetwarzanie moich danych osobowych w PMS. Jednocześnie zgadzam się na udostępnianie ww danych operatorowi statków w ramach działań mających na celu moje zatrudnienie.
	I hereby certify, that the information in the forms is correct and I understand that the Employer has right to terminate my service if any of the above information is found to be false.