za pomorske usluge - shipping services ltd. - ŠIBENIK - CROATIA
Obala Hrv. mornarice 1 - P.O. Box 142 - tel. +385 (0)22 - 213 750 - fax: 385 (0)22 - 213 751
E-mail: info@pasat.hr
 
1.Personal description and information

Position applied for
   
Name and surname
Father's name
Mother's name
Nationality
Date of birth
Place of birth
Gender M F
Matrimonial status
Permanent address
Street
City
Country
Telephone
E-mail
Mobile phone
Nearest airport
Foreign languages
Secondary Maritime School
Higher degree maritime academy

Seaman's book Passport
  Issued by
  Number
  Place of issue
  Date of issue
  Date of expiry
  USA Visa expiry date
  Date of last medical
  Yellow feewer vaccine expiry date :
2. Next of a kin

Name and surname
Date of birth
Relationship
Permanent address
Street
City
Telephone
3.Account details

Bank
Address
Country
Account no.

4.Certificates

Certificates Expiry - date Issue - Date Place of Issue Certificate No.
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5.Previous sea service - last 5 years

Vessels name Flag Type Engine:Type/HP
Deck:GT-TEU 		Owner
/ Manager		 Rank Period
From Till

I herewith certify that the above information are true and accurate to the best of my ability and that no certificate of competence or licence issued to me has ever been revoked or suspended.

An employment becomes effective only after the Contract of employement has been signed.