Lerus Training - Application Form

TRAINING COURSE APPLICATION FORM
Please complete the form in BLOCK CAPITALS.
COURSE APPLIED FOR:

Course Title: Date of course:
PART A: DETAILS OF APPLICANT (as they appear in your seaman book)

Title: Mr/ Mrs/ Ms/ Miss/ Other (Please specify): Male / Female (circle one)
Family name: Date of birth:
First name(s): Nationality:
Middle name: Rank/ Job title:
Home address: Home phone:
Mobile phone/ Cell phone:
e-Mail:
Country:
Most of our courses require a good level of written and spoken English. Please indicate your proficiency in English:
1=Poor; 2=satisfactory; 3=good
Write ( ) Read ( ) Speak ( )
Do you have any medical conditions we should be aware of?

Yes / No If “Yes”, please give details
Emergency contact / Next of Kin

Full Name Address Phone Number Relationship
Accommodation (Please tick appropriate): Required Not Required
PART B: DOCUMENTS OF APPLICANT (Please provide applicable)

Document Grade Number Date of issue Place of issue Valid until
Seaman’s
Book
Certificate of
Competency
Endorsement
DP Certificate
PART C: EXPERIENCE OF APPLICANT

How long have you been in the industry? Length of time in current role:
Please state the last 3 vessels:
Owner or
Vessel Type/DWT Flag DP Class Engine/BHP Rank From To
Manager
PART D: DETAILS OF PAYMENT
Rev.04 – 01.02.2022 Page 1 of 2

Payment Method (Please tick appropriate) Cash Invoice
INVOICING DETAILS (If applicable)
Organisation name:
Address: Telephone number:
Mobile phone/ Cell phone:
e-Mail:
Country:
PART E: General Conditions:

Registration and application:
Acceptance onto a Training Course at Lerus Training Center is subject to a successful application procedure (including but not limited the following:
completion of application form, meeting of prerequisite training requirements and passage of interview if required,). You will be notified at the end of the
procedure whether or not you can be accepted onto the course. Final reconfirmation will be made upon full payment the Training Course to be carried out
by Applicant.
Payments:
Payments may be made by all major credit and debit cards, except American Express cards; cash payment is acceptable or LTC will provide Invoice for
Organisation mentioned in Part D. Credit is not granted to private delegates or to individuals under any circumstances. Balance of payment is due no later
one week before the start of the course.
Cancellation fees:
All cancellations must be made in writing. For cancellations received up to 20 working days (4 weeks) prior to the start of the course Lerus Training will
refund 100% of the course fee. Cancellations received after 20 working days (4 weeks) till 5 working days (1 week) before the start of the course will be
charged the 50% of course fee. Full course fee will be charged for cancellation within 5 working days (1 week) prior the start of the course. If the delegate
fails to attend the course, the whole course fee will be charged. If you cancel or withdraw after the start of the course, no refund will be given.
Non-disclosure of a health problem before the course starts means that no refund will be possible once the course commences
Amendments:
Any amendments must be made in writing. Amendment of the booking within 5 working days (1 week) prior the start of the Course and shift of intended
Course within the three months of the previously booked, will lead that in addition to the charged original Course fee the subsequent Course should be
paid with additional 50% of Course fee and no further changes of Course date or name of delegate on the booking will be permitted.
Other amendments to be accepted without any charges.
Should the required minimum number of candidates not be reached, the course will be postponed to a future date. Candidates will be kept fully informed
of projected course details and monies will be refunded.
Whilst every endeavor is made to ensure courses are run as scheduled, on occasions there is a need to postpone or cancel a course. In such circumstances,
all fees paid in advance will be held for use against a future course or can be requested to be refunded.
Insurance:
Candidates are not insured by Lerus Training against illness, accident, theft or any loss of personal effects. Lerus Training and its principals cannot accept
responsibility for any accident occurring during the course, on or off the center premises or during activities.
Place of Jurisdiction:
Place of jurisdiction in any dispute: the courts at Odesa, Ukraine.
Confidentiality Policy:
Lerus Group is committed to protecting the privacy of its customers and the security of their personal information. We collect information clearly and
transparently and communicate how we will process the data. You can find out more about our Confidentiality Policy on our website.
I hereby declare that all information supplied by me is to the best of my knowledge true and correct. I understand and agree to be bound by the General
Conditions stated herein. I agree to be bound by the payment time table. I have read and agree to abide by the conditions pertaining to refunds.
I understand and agree with LERUS GROUP Confidentiality Policy. I agree that my personal information may be shared to third parties for the certification
and auditing purpose.
Signature of applicant: Date:
All the rows below are for LTC Official use only
Events Booked & informed Acceptance Reconfirmation call Rejection letter
Secretary/Ch.Instructor letter/date
(Please record the
dates)
Cancellation by Date Reason % refund/approval Refunded
applicant
Finance Officer: Fee Invoice sent /date Payment Cash received/ date
status? received /date
(Please record dates) Date:
Instructor’s Accepte Not Other comments
review/response d accepted
Top Management
Approval for discounted
fee (%, date, name)
Rev.02 – 01.02.2022 Page 2 of 2

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TRAINING COURSE APPLICATION FORM

Please complete the form in BLOCK CAPITALS.

COURSE APPLIED FOR:

PART A: DETAILS OF APPLICANT (as they appear in your seaman book)

Family name: Date of birth:

First name(s): Nationality:

Middle name: Rank/ Job title:

Home address: Home phone:

Mobile phone/ Cell phone:

Do you have any medical conditions we should be aware of?

Emergency contact / Next of Kin

Accommodation (Please tick appropriate): Required Not Required

PART B: DOCUMENTS OF APPLICANT (Please provide applicable)

PART C: EXPERIENCE OF APPLICANT

PART D: DETAILS OF PAYMENT

Rev.04 – 01.02.2022 Page 1 of 2

Address: Telephone number:

Mobile phone/ Cell phone:

PART E: General Conditions:

Rev.02 – 01.02.2022 Page 2 of 2

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