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Application Form and
Record of Personal Information and Past
Experience
Doc No:
Valid From:
Version:
Author:
Marine HR TKG - 51
28/06/2005
1
John
Williams
Please complete
the attached form by hand or electronically (you
can type directly in the fields
provided). Please send the completed
application to @, or fax it to
+44
(141) 243 2100.
Present rank:
Name in full (First, Middle, Last)
Date of birth
Place of birth
Permanent /
Contact address
Age
Rank applied for:
Nationality
Married / Single / Divorced
/
Widower
Next of kin
Name
Relationship
Address
(include international dialing code)
Telephone number
Nearest airport
If
accepted, date available for service:
Medical certificate expiry
date:
Yellow fever vaccination expiry date:
Professional
Qualifications
Licences
National
(please state)
Bahamian
Liberian
Panamanian
Grade of
licence
Number
Date issued
Place issued
/ Revalidated
Expiry Date
U.S. Visa
Other Visa
Other Visa
Type
Type
Type
Valid until
Valid until
Valid until
Colour of hair
/ eyes
/
Height
Weight
Mobile number
Fax number
Email address
Date:
Photo
Application
Form and
Record of Personal Information
and Past
Experience
Doc No:
Valid From:
Version:
Author:
Marine HR TKG - 51
28/06/2005
1
John
Williams
Expiry date
Seaman’s book
number /
Nationality
Referees:
Name, company
and contact
telephone number
Place & date
issued
1)
Expiry date
Passport
nationality /
Number
Place & date
issued
2)
Other professional
qualifications / Certificates / Endorsements held
Course / Certificate
Signature:
Place held
Date held
Date of expiry
Application Form and
Record
of Personal Information and Past Experience
Doc No:
Valid From:
Version:
Author:
Marine HR TKG - 51
28/06/2005
1
John
Williams
Previous Sea
Experience
Vessel name
Flag
Deck: Trading area /
Deadweight
Engine: Type &
BHP
Type of
vessel
Company
name
Rank
Period
From
–
To
2
Last
rd
nd
Days /
Months
Last
/
/
3
Last
th
/
4
Last
th
/
5
Last
th
/
6
Last
th
/
7
Last
th
/
8
Last
th
/
9
Last
/
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