STARGATE MARITIME LTD.

Head Office: 3rd Floor, Office Nо5, Sofia Street, 9001 Varna, Bulgaria
Tel: + 359- (0)52- 91 99 95; Fax: + 359 (0)52 – 63 14 65 E-mail: office@stargatemaritime.com

APPLICATION FORM
PHOTO

RANK _______________

І. PERSONAL DATA :

Name: Father’s Name: Family Name:

Date of birth: Place of birth: Personal No (EGN):
Address:

Mobile Phone: Other Phone: E-Mail:

Education: NAVAL ACADEMY OTHER

TECHNICAL UNIVERSITY
Qualification: Diploma No: Issued on:

English Language: Average / Good / Very Good

ID Card No: Date of issue: Issued by:

ІІ. RELATIVES :

WIFE : ______________________________________/__________________/__________
FULL NAMES EGN PLACE OF BIRTH

CHILDREN:1._____________________________________/__________________/__________
2._____________________________________/__________________/__________
3._____________________________________/__________________/__________
FULL NAMES EGN PLACE OF BIRTH

PARENTS:
Mother : ____________________________________/__________________/__________
Father : ____________________________________/__________________/__________
FULL NAMES EGN PLACE OF BIRTH

HEIGHT : SHOES № : WEIGHT : kg

ІІІ. DOCUMENTS

BULGARIAN No. ISSUED VALIDITY

Certificate of Competency, Rank …………………. (STCW as amended)
International Passport
Seaman's Passport
Seaman’s Discharge Book

CERTIFICATES - STCW (AS AMENDED)

BASIC SAFETY TRAINING - Reg.VI/1 ,A-VI /1 p.2
SURVIVAL CRAFT AND RESCUE BOAT OTHER THAN FAST RESCUE
BOAT - Reg.Vl/2, Section A - VI/2, p.1
ADVANCED FIRE FIGHTING - Reg.VI/3, Section A-VI/3 p. 1
MEDICAL FIRST AID - Reg. VI/4, p.1 , Section A-VI /4, p.1
MEDICAL CARE ON BOARD - Reg.VI/4, p.2, Section A-VI/4, p.4-6 (Master,
Chief Off. and Second Off.)
TRAINING IN MARINE ENVIRONMENTAL AWARENESS
OPERATIONAL USE OF ELECTRONIC CHART DISPLAY AND
INFORMATION SYSTEMS (ECDIS) - IMO Model Course 1.27 – (Deck
Officers)
BRIDGE TEAM AND RESOURCE MANAGEMENT - Section A-VIII/2 of the
STCW Code, IMO Model Course 1.22 – (Deck Officers)

PROFICIENCY FOR SHIP SECURITY OFFICER - Regulation VI/5, para 1 to

2 – (Master and Chief Off.)

PROFICIENCY FOR SEAFARERS WITH DESIGNATED SECURITY

DUTIES - Section A-VI/6, para 6 to 8

ENGINE TEAM AND RESOURCE MANAGEMENT - Chapter III and Chapter

VIII of the STCW 78, as amended and Section A-VIII/2 of the STCW Code, IMO
Model Course 2.07 – (Engine Officers)
MONITORING AND OPERATION OF MAIN AND AUXILIARY
MACHINERY AND ASSOCIATED CONTROL SYSTEMS – Chapter III and
Chapter VIII of the STCW 78, as amended and Section A-III/1 & A-VIII/2 of the
STCW Code – (Engine Officers)
OPERATION AND MAINTENANCE POWER SYSTEM IN EXCESS OF 1000V
- Chapter III and Chapter VIII of the STCW 78, as amended and Section A-VIII/6
of the STCW Code

Others:

USA Visa C1/D

Yellow Fever Vaccination
 IV. SEA SERVICE

COMPANY VESSEL FLAG TYPE GT MAIN ENG. RANK SEA SERVICE DURATION
TYPE/KW Sign on Sign off month day

YES NO
V. ATTACHED SEA SERVICE RECORD

DATE: __________________ SIGNATURE: ____________________

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