PART I : Personal data

Fields marked with (*) are mandatory !

Fields marked with (~) only one is mandatory !

* Your Rank


* Name * Surename ~Identification code (CNP) * Permanent address
City Country * Date of birth Place of birth
Email * Phone Phone 2 (Mobile)
ITALIAN FISCAL CODE (if any) Next of Kin (NOK) NOK Phone NOK Relationship

Document Number Issued Place Valid until
~ Passport
Seaman`s book

Family Data

Name Date of birth Address Phone Relation

PART II : certificates / courses / Highest Competency certificate held


Issuing authority Grade / Level Certificate No. Date of issue Validity
National Certificate of Competency
STCW 95/ Endorsement

Certificates Place issued Number Date issued Valid until
LIQ. GAS TANKERS
OIL TANKERS
CHEMICAL TANKERS
TANK FAMILIARIZATION
RO-RO PASSENGER SHIPS/PASSENGER SHIPS OTHER THAN RO-RO PASSENGER SHIPS A-V/2;A-V/3
PROFICIENCY IN FAST RESCUE BOATS A VI/2
SHIP SECURITY OFFICER

DYNAMIC POSITION CERTIFICATES Place issued Number
BASIC / INDUCTION DP
ADVANCED DP
MAINTENANCE DP ( ENGINE OFFICERS ONLY )
FULL DP
BASIC OFFSHORE SAFETY INDUCTION & EMERGENCY TRAINING
HELICOPTER UNDERWATER ESCAPE TRAINING INCLUDING EBS
FURTHER OFFSHORE EMERGENCY TRAINING

RATING COURSES / STCW-95 CODE Place issued Number Date issued Valid until
TRANSPORT AND HANDLING OF DANGEROUS, HAZARDOUS AND HARMFUL CARGOES A-II/4,A-III/4
MARITIME ENGLISH LANGUAGE TRAINING PHRASE VOCABULARY A-III/4
PREVENTION OF MARINE POLLUTION FROM SHIPS A-II/4,A-III/4
BASIC FIRE-FIGHTING A-VI/1-2
PERSONAL SAFETY AND SOCIAL RESPONSIBILITIES ON BOARD SHIPS A-VI/1-2
PERSONAL SURVIVAL TECHNIQUES A-VI/1-2
ELEMENTARY FIRST AID A-VI/1-2
SECURITY AWARNESS TRAINING and SECURITY TRAINING FOR SEAFARERS WITH DESIGNATED SECURITY DUTIES Reg. VI/6 1-3,4-6;A-VI/6 1-4, 6-8
SHIP'S COOK SPECIALIZATION
HUMAN ELEMENT, LEADERSHIP AND MANAGEMENT

OFFICERS COURSES / STCW-95 CODE Place issued Number Date issued Valid until
TRANSPORT AND HANDLING OF DANGEROUS, HAZARDOUS AND HARMFUL CARGOES A-II/1,A-II/2,A-III/1,A-III/2
MARITIME ENGLISH A-III/1, A-III/2; AII/1, A-II/2
PREVENTION OF POLLUTION OF THE MARINE ENVIRONMENT-MARPOL73/78- A-II/1,A-II/2,A-III/1,A-III/2
PROFICIENCY IN SURVIVAL CRAFT AND RESCUE BOATS, OTHER THAN FAST RESCUE BOATS A-VI/2,1-4
ADVANCED FIRE-FIGHTING A-VI/3
PERSONAL SAFETY AND SOCIAL RESPONSIBILITIES ON BOARD SHIPS A-VI/1;2.1.1.4
PERSONAL SURVIVAL TECHNIQUES A-VI/1,2.1.1.1
MEDICAL CARE A-VI/4-4-6// MEDICAL FIRST AID A-VI/4-1-3
RO-RO PASSENGER SHIPS/PASSENGER SHIPS OTHER THAN RO-RO PASSENGER SHIPS A-V/2;A-V/3
PROFICIENCY IN FAST RESCUE BOATS A-VI/2-1-4
BRIDGE TEAM AND RESOURCE MANAGEMENT A-VIII,B-VIII
RADAR NAVIGATION,RADAR PLOTTING AND USE OF ARPA operational level A-I/12,A-II/1
RADAR ARPA,BRIDGE TEAMWORK AND SEARCH AND RESCUE-management level A-I/12,A-II/2
GENERAL OPERATOR FOR GMDSS(GOC) COURSE A-IV/2
GMDSS A-IV/2
SHIP SECURITY OFFICER A-VI/5
ENGINE TEAM AND RESOURCE MANAGEMENT A-III/2
ELECTRONIC CHART DISPLAY AND INFORMATION SYSTEM A-II/1; A-II/2
SHIP HANDLING AND MANEUVERING SYSTEM A-II/1
TANK FAMILIARIZATION /A-V/1; 1-7
SPECIALIZED OIL TANKER/ A-V/1;8-14
SPECIALIZED CHEMICAL TANKER/A-V/1;15-21
SPECIALIZED GAS TANKER/ A-V;22-34

PART III : Sea Experience - Most recent experience on top line


Company Vessel Type DWT HP Main Engine Rank Date from Date to Reason

TYPE: OIL/TK (OIL TANKER),  CH/TK (CHEMICAL TANKER),  LPG/TK (LPG TANKER),  LNG/TK (LNG TANKER),  RO (RO-RO),  PAX (PASSAGER),  BK (BALK),  FERRY (FERRY),  GC (GENERAL CARGO),  CON (CONTAINER),  SUPPLY (SUPPLY VESSEL),  OH (OFF SHORE),  FPSO (FPSO),  AHTS (ANCHOR HANDLING),  TUG (CRANE BARGE),  OIL/CH TK (OIL/ CHEMICAL TANKER)  LPG-OIL/CH TK (LPG OIL/ CHEMICAL TANKER)  PSV (PIPE LAY VESSEL)  MPC (MULTIPURPOSE VESSEL)  MPSV (MULTIPURPOSE SUPPORT VESSEL)  ARV (ACCOMMODATION REPAIR VESSEL)  RO-PAX (RO-RO PASSAGER) 


REASON: EOC (End Of Contract),  SS (Ship Sold),  COM (Change Of Management) 


Notes to sea experience

Deck officers & Pumpman:

A. Indicate type of cargoes loaded:


B. Where you loading different cargoes simultaneously?

C. Which kind of pumps you have been experienced with?

ENGINE /ELECTRICIANS OFFICER ONLY:

A. Please state if you have been sailing with UMS and which remote control systems are familiar to you:


B. MAIN ENGYNE TYPES:
        - 2 STROKES MONTHS
        - 4 STROKES MONTHS
C. PROPULSION TYPE:
        - FIXED PROPPELER MONTHS
        - CONTROLLABLE PITCH PROPELLER(CPP) MONTHS
D. INERT GAS GENERATOR TYPE:

        BOILER INDEPENDENT BURNER UNIT NITROGEN PLANT

E. BOILER TYPE:

        STEAM THERMAL OIL

F. CARGO PUMPS:

        ENGINE DRIVEN ELECTRIC DRIVEN STEAM DRIVEN HYDRAULIC DRIVEN(FRAMO)

G. WORKING WITHOUT ELECTRCIAN :

H.WORKING WITH REDUCED ENGINE PERSONNEL-Please list the ranks present on board.


PART IV : general

A. Have you ever been denied for a foreign visa?


B. Have you been the subject of a court of inquiry or involved in a marine accident?


C. Nearest airport:

LANGUAGES

English
French
Italian
Spanish
German
Other

VISAS

Visa Availability
SUA
BRAZIL
DUBAI

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