MALTABULK HOLDING S.

A 001/CRW/SAF

SEAFARER’S APPLICATION FORM

A. PERSONAL DETAILS
Rank applied for:       Alternative:      
Surname:       First name:       Middle:      
Place of birth:       Nationality:       Date of birth:       FOTO

Permanent address:      

Phone (Home):       Phone Mob:       Email:      

Nearest Airport:       Marital Status ( married, single, divorced):      
Next of Kin (NoK):       NoK Contact Details:      
Address NoK:       Nr of Children Under 18 y.o:      
Colour of Eyes:       Colour of Hair:      
Height:       Overall Size:       Shoes Size:      

B. QUALIFICATION AND DOCUMENTATION CHECKLIST

expiry issue
Tick Documents № issue date
date place
1. NATIONAL DOCUMENTS
Travel Passport                        

Seaman’s Passport                        

Certificate of Competency (CoC)
                       
Capacity:      
Endorsement of CoC
                       
Capacity:      
GMDSS CoC
                       
Capacity:      
Endorsement of GMDSS CoC
                       
Capacity:      
Basic Safety (A-VI/1-1,2,3,4)                        

Survival Craft & Rescue Boats (A-VI/2-1 )                        

Advanced Fire Fighting (A-VI/3)                        

Medical Care on Board (A-VI/4-2)                        

Medical First Aid (A-VI/4-1)                        

Ship Security Officer (A-VI/5,B-VI/5)                        

Radar & ARPA Operational Level (A-I/12,A-                        
II/1)
Radar & ARPA Managem. Level (A-I/12,A-                        
II/2)
Operational use of ECDIS (A-II/1, A-II/2)                        

Hazmat in Bulk (B-V/b)                        

Security Training for Seafarers with
                       
Designated Security Duties (A-VI/6-2)
Food Handling and Personal Hygiene (MLC)                        

Int. Yellow Fever Vaccination                        

Other vaccination :                              

                             

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MALTABULK HOLDING S.A 001/CRW/SAF

expiry issue
Tick Documents № issue date
date place
2. FLAG REQUIREMENTS
Flag Seaman’s Passport                        

Flag Endorsement for CoC                        

Flag Endorsement for:                              

Flag Endorsement for:                              

Flag Endorsement for:                              

3.OTHER DOCUMENTS
Valid U.S.A. visa                        

Valid visa                        

4. ADDITIONAL CERTIFICATES
                             

                             

C. EDUCATION
Graduated from:       Year:      
     

D. DETAILS OF PREVIOUS SEA SERVICE (last 5 years)

POSITION COMPANY NAME OF VSL TYPE ENGINE DWT BHP FROM TO

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

E. DETAILS OF LAST EMPLOYERS WHO WE MAY CONTACT FOR REFERENCE

Company            

Name of Person to Contact            

Contact Details            

I hereby declare that the above all data is true. Further I understand and confirm that this data will be stored in shipowners’ database and will be used for all purposes related to
my application for employment on board vessels managed by Maltabulk and may involve the transfer of my personal data within Maltabulk or to third parties worldwide.

SEAFARER’S NAME:       SIGNATURE DATE:      

F. COMPETENCY TEST / INTERVIEW (FOR OFFICE USE ONLY)

Last Employers Reference Results       English Test / Interview Date/Signature:      

Crew Manager:       Date/Signature:       DPA/SQMR:       Date/Signature:      

Technical Manager :       Date/Signature:       General Manager :       Date/Signature:      

VALID REASON:       NOT VALID

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