F-113A/01.

14

Application form – Diverso Impex

Maritime education center and crewing agency

Personal Information
Surname, Given name
Rank applied for
Nationality
Father's name
Mother's name
Marital status
OIB
Date of birth
Place of birth
Present address
Mobile phone (cellphone)
Telephone (landline)
E-mail
Nearest airport
Height in cm
Weight
Next of kin
Next of kin address
Education (school/college)
Previous salary
Expected salary

Please send filled Application form to e-mail address: diverso@diversoimpex.hr

 F-113A/01.14

Application form – Diverso Impex

Maritime education center and crewing agency

Passport
Number Place issued Date issued

Seaman's book
Country Number Place of issue Date of issue Date of expiry

Certificate of Competency (CoC)

Country Grade of license Number Place of issue Date of issue Date of expiry

Certificates STCW
Country License Number Place of issue Date of issue Date of expiry

Medical Date of issue Date of expiry

Medical exam
D&A test
CB test
Yellow fever

Please send filled Application form to e-mail address: diverso@diversoimpex.hr

 F-113A/01.14

Application form – Diverso Impex

Maritime education center and crewing agency

Experience (in last 5 years or last 10 ships served)

Ship name Engine* Power* Type of Company Flag Rank From To
vessel dd.mm.yyyy dd.mm.yyyy
Trade ** DWT**

* For Engine officers

** For Deck officers

_________________________ _________________________
Date Signature

www.diversoimpex.hr DIVERSO IMPEX d.o.o. diverso@diversoimpex.hr

Tel: +385 21 453 040 Velebitska 123 Fax: +385 21 453 048
21 000 Split
Croatia

Please send filled Application form to e-mail address: diverso@diversoimpex.hr