application for employment - lil-12 · date: ..... ready for employment : ..... e- mail:
TRANSCRIPT
Date: .......................................Ready for employment : .......................................E- mail: .......................................
1. Family name ..............................., First name .........................., Father's name ..............................2. Date of birth ...................................... 3. Place of birth: ...................................................................4. Nationality ........................................, Religions denominations ......................................................5. Identity card ............, № ....................., Date of issue ......................................................................Place of issue ............................................, ID № (ЕГН) .....................................................................6. Height ................., Weight ....................., Eyes color ...................., Hair color: ................................Overall №: ......................... Shoes №: ..................................., Preferred vessels: ..............................7. Marital status ................................................, Nearest Airport: ........................................................8. Present address .........................................., Str. ........................................................, № .............................................................................................................................................................................9. Tel. Number: ...............................................10. Next of kin / full name / ..................................................................., Address ............................................................................................................ Tel.: ........................... Relations: .............................11. Have you any health problems: ....................................................................................................................................................................................................................................................................12. Education .................................., Diploma № .......................... From: ........................................... Speciality: ............................................, Period: from .......................... to ......................, address ...............................................................13. Previous sea servise in years: ......................................................................................................................................................................................................................................................................14. Do you speak English Fluently: ........................ Read: ......................... Write: ..............................
Passed English test (Yes/No): ....................., (Marlins/CES/SETS), Percentage:..........................
phone: + 359 52 33 54 55 fax/phone: + 359 52 33 53 34phone: + 359 52 33 55 03 mobile: + 359 890 145 700mobile: + 359 887 272 672 mobile: + 359 899 145 700
Application For EmploymentRANK APPLIED FOR: .................................
photo
LIL - 12 v.4/2013 fr 01/02/01
58, Debar str., floor 5, Varna 9000, BULGARIAe-mail: [email protected], www.lil-12.com
15. What other languages do you speak:..............................................................................................
17. Seaman's book ...................... No ...................... Issued ........................ Date ............................... Expire date ........................................................18. International passport ........... No ...................... Issued ........................ Date ............................... Expire date .................................................
20. Flag Endorsements (if any)
21. STCW Certificates
LIL - 12 v.4/2013 fr 01/02/01
COUNTRY LICENCED AS CERTIFICATE NUMBER DATE OF ISSUE
CERTIFICATIONSPersonal Survival TechniquesFire Preventions & Fire FightingElementary First AidPersonal safety & Social ResponsibilitesProficiency in Survival Craft
MSRC, Radar&Operational use of A.R.P.A
Proficiency in Medical First Aid
SSO / SDSD / SSA
Competency in Advanced Fire Fighting
Medical Care
Fast Rescue Boat
Bridge/Engine Team and Res. Management
Oil Tanker FamiliarizationChemical Tanker Familiarization
HUET
HAZMAT
REFERENCE NUMBER DATE OF ISSUE
Chemical Tanker OperationsOil Tanker Operations
DP Certificate
16. Seafarer's passport ............... No ...................... Issued ........................ Date ............................... Expire date ........................................................
COUNTRY LICENCED AS CERTIFICATE NUMBER DATE OF ISSUE
19. Certificate Of Competency
COUNTRY LICENCED AS CERTIFICATE NUMBER DATE OF ISSUEBULGARIA
ECDIS
HLO
Marine Environmental Awareness
PeriodFrom To
RankVessel
Name Type GT
Main Engine
Type KWEmployer Flag
22. Previous Sea Service (last 6 contracts)
LIL - 12fr 01/02/01
v.4/2013
AUTOBIOGRAPHY
Of ..........................................................................................................................................................Address: .............................................................................................. Tel.: .........................................Date of birth: .................................................. Place of birth: ...............................................................Mother: ...................................................................................... Date of Birth: ....................................Father: ....................................................................................... Date of Birth: ....................................Brother: .................................................................................................................................................Sister: ...................................................................................................................................................Wife: ..................................................................................................................................................... Date of birth: ............................................... Place of birth: ..........................................................Children: 1. ....................................................................................................................................... 2. ....................................................................................................................................... 3. .......................................................................................................................................Military service: .............. Period: from ......................... to ....................... Position: ............................Ex-company name: ..............................................................................................................................Address: .............................................................................. Phone: ....................................................Contact person name: ..........................................................................................................................Position : ............................................................................. Phone: ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Information for the experience of the seafarer........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Signature: ......................................
LIL - 12 v.4/2013 fr 01/02/01
23. Diplomas and certificates for fitters, cooks, stewards ..................................................................... ......................................................................................................................................................24. USA Visa Issued date: ........................................, Expired date: ............................................................
25. Yellow Fever Issued date: ...................................., Other vaccinations: ..........................................