Seafarer Application

DÖHLE MANING AGENCY (POLAND) LTD

Passport
10 Lutego str.10 ,PO Box 379, 81-301 Gdynia 1, photo
Tel: +48 58 660 6099 , +48 58 660 8066 ,Fax: +48 58 660 5770 ,
E-mail: [email protected] ,www.doehle-poland.com

Rank Surname 1st Name(s)

Date of Birth Place of Birth Nationality
Marital Status No. of Children Phone
Mobile Phone
Full Address
E-Mail Address
Nearest Airport Availability Date
Next of kin Relationship Phone
Address
Education Year completed
Identity-/ Travel Documents Nationality Type Number Place of Issue Issued Expiry
Passport
US-Visa
Other Visa
Seaman Book
Seaman Book
Medical Certificates Nationality Type Number Place of Issue Issued Expiry
Certificate of Medical Fitness
Yellow Fever Vaccination
Certificates - Courses Nationality Position Number Place of Issue Issued Expiry
Certificate Of Competence
Certificate Of Competence
Certificate of SSO
General Operator Cert. (GMDSS)
Basic Safety Training
Proficiency Survival Craft
Proficiency Fast Rescue Boats
Advanced Fire Fighting
Medical First Aid
Medical Care
HAZMAT (US-Trading)
ARPA
ECDIS

Experience-Knowledge Subject or Hard- / Software Self Evaluation (please tick)

Language Knowledge English Good Satisfactory Nil / Poor
Language Knowledge Good Satisfactory Nil / Poor
Electr. Chart Display System Good Satisfactory Nil / Poor
Computer Experience Microsoft Windows Good Satisfactory Nil / Poor
Computer Experience Microsoft Office (Word, Excel) Good Satisfactory Nil / Poor
Stability / Cargo Planning System Seacos Good Satisfactory Nil / Poor
Other Stability / Cargo System Good Satisfactory Nil / Poor
Planned Maintenance System CODie ISMAN Good Satisfactory Nil / Poor
Other Planned Maintenance Syst. Good Satisfactory Nil / Poor
Working Experience Monitor / Maintain Reefer Containers Good Satisfactory Nil / Poor
Working Experience Operate / Maintain Ship's Cranes Good Satisfactory Nil / Poor
Working Experience Automation Systems Good Satisfactory Nil / Poor
Working Experience Common Rail M.E. Good Satisfactory Nil / Poor
Working Experience ISM - Systems / - Audits Good Satisfactory Nil / Poor
Please state Nationalities of Seafarers you sailed with:
Senior Officers
Junior Officers
Ratings
 Sea-Service (most recent vessel first)
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area
Rank Vessel Type GRT DWT TEU

From To Main Engine Power Vessel's

Make - Type kW Flag
Employer Charterer Trading
Area

By sending this application I am accepting below terms and condition:

1) I hereby affirm that all the information provided by me is true and correct to the best of my knowledge and belief. I further affirm that no certificate of Competency or License issued to me has ever
been revoked or suspended. I understand that previous employers may be asked for information concerning my employment record with them and I hereby release from liability or damage those
individuals or companies who provide such information.
2) I hereby agree to the use of my personal data included in my job application as acquired by the recruiting process (according to the Polish law of August 29,1997 in respect of a protection of personal
data Dz. Ust. Nr 133 poz.833).