BARKLAV SRL

System Manual Office Forms Manual

(FM)
Chapter: 01 First Issue: 01 Rev.No : 08
Application Form (Sea Staff) Section: 01 Date: 01/07/00 Date : 21/12/16
Page: 1 of 5 Appr. by: GM Appr.by: GM

Registered at A.N.S.P.D.C.P under number 22766/2012 SURNAME (NUME) :

RANK APPLIED FOR (FUNCTIE) : NAME (PRENUME) :

WILLING TO ACCEPT LOWER RANK (YES/NO) : NATIONALITY (NATIONALITATE) :

PERSONAL DETAILS (DETALII PERSONALE)

HEIGHT (INALTIME) :
PLACE OF BIRTH (LOCUL NASTERII) : PLEASE ATTACH PHOTO
MOTHER LANGUAGE (LIMBA MATERNA) : HERE
(ATASATI POZA AICI)
OTHER LANGUAGES (ALTE LIMBI STRAINE CUNOSCUTE) :
NEAREST INTERNATIONAL AIRPORT (CEL MAI APROPIAT AEROPORT INTERNATIONAL) :
MILITARY STATUS (STAGIU MILITAR) NOT SATISFIED
PARENTS (PARINTI) MOTHER NAME (MAMA) : FATHER NAME (TATA) :
PRESENT ADDRESS (ADRESA ACTUALA) :

e-mail address:
PHONE (TELEFON NR) :
NEXT OF KIN NAME, RELATIONSHIP AND ADDRESS (NUME, GRAD DE RUDENIE SI ADRESA PERSOANEI IMPUTERNICITE):

PHONE (TELEFON NR):

WIFE AND CHILDREN NAMES DATE OF PASSPORT VALIDITY ISSUING ISSUING PLACE
(NUMELE SOTIEI SI COPIILOR) BIRTH NUMBER (NUMAR AUTHORITY (LOCUL EMITERII)
PASAPORT) ISSUE EXPIRY (AUTORITATEA
(DATA (DATA EMITERII)
(DATA EMITENTA)
NASTERII)
EXPIRARII)

DOCUMENTS DOC. NO ISSUED EXPIRES ISSUING AUTHORITY ISSUING PLACE

(NUME DOCUMENT) (SERIE) (EMIS) (EXPIRA) (AUTORITATEA EMITENTA) (LOCUL EMITERII)
PASSPORT

SEAMAN'S BOOK NATIONAL

SEAMANS BOOK FLAG STATE 1

SEAMANS BOOK FLAG STATE 2

US VISA C1/D TYPE

AUSTRALIAN MCV

OTHER VISAS

MEDICAL ILO CERTIFICATE

VACCINATION YELLOW FEVER

COLLEGES / INSTITUTES (STUDII ABSOLVITE)

NAME OF INSTITUTION COURSE ATTENDED DATES QUALIFICATIONS
(NUMELE INSTITUTIEI) (CURS ABSOLVIT) GAINED
FROM TO (CALIFICAREA PRIMITA)
 BARKLAV SRL
System Manual Office Forms Manual
(FM)
Chapter: 01 First Issue: 01 Rev.No : 08
Application Form (Sea Staff) Section: 01 Date: 01/07/00 Date : 21/12/16
Page: 2 of 5 Appr. by: GM Appr.by: GM

CAREER DETAILS
DETAILS OF LICENCES / ENDORSEMENTS ( DETALII DESPRE CERTIFICATE/LICENTE)
QUALIFICATIONS DOC. NO RANK STCW REG. DATE ISSUING
(CALIFICARI) (NUMAR) ( FUNCTIA) ISSUED (EMIS LA) EXPIRE (EXPIRA LA) AUTHORITY
(EMIS DE)
NATIONAL LICENSE
NATIONAL ENDORSEMENT
NATIONAL LICENSE 2 (IF APPLICABLE)
GMDSS ENDORSEMENT
SSO ENDORSEMENT
TANKER FAMILIARISATION
(OIL & CHEM) ENDORSEMENT
TANKER FAMILIARISATION
(GAS) ENDORSEMENT
ADVANCED OIL TANKER
ENDORSEMENT
ADVANCED CHEM TANKER
ENDORSEMENT
ADVANCED GAS TANKER
ENDORSEMENT
RECORD OF PREVIOUS SERVICE (LAST EMPLOYMENTS) (SEA SERVICE)
SIGN ON SIGN OFF
SHIP PARTICULARS (DETALII CONSTRUCTIVE)
DE LA LA
COMPANY RANK
POZITIA LA TYPE MAIN ENGINE
COMPANIE
BORD
NAME FLAG DWT BUILT
TIP POWER
NUME NAVA PAVILION TONAJ AN TYPE TIP
NAVA KW

SUMMARY OF SEA SERVICE IN MONTHS FOR ALL CAREER ( SEA SERVICE IN LUNI PE TIPURI DE NAVE)
DRY TANKER OFFSHORE TOTAL (TOTAL)
RANK (FUNCTIE) PROD/ CRUDE AHTS /
BULK CONTAINER LPG / LNG FSO /FPSO DP VSLS
CHEM OIL SUPPLY

SUMMARY OF EXPERIENCE ON ENGINE TYPE IN MONTHS FOR ALL CARRIER (ENGINEERS APPLICANTS ONLY)
ENGINE TYPE UNATTENDED 2 STROKE/ 4
MAN SULZER B&W PIELSTICK MAK TOTAL
RANK MACH SPACE STROKE M.E.
 BARKLAV SRL
System Manual Office Forms Manual
(FM)
Chapter: 01 First Issue: 01 Rev.No : 08
Application Form (Sea Staff) Section: 01 Date: 01/07/00 Date : 21/12/16
Page: 3 of 5 Appr. by: GM Appr.by: GM

OPTIONAL - Please detail your experience (structured per each vessel) on various equipments OR any other relevant details
EXAMPLE:
May 2010 March 2016, Ship / Unit: FREEDOM, Rank:
Operate, maintain, troubleshooting and repair equipment such as: Internal combustion engines (2 strokes, 16V, GENERAL MOTORS
EMD645E9); Azimuth Thrusters (HOLLAND ROERPROPELLER); Tunnel Thrusters ( BAYLOR); ETC
 BARKLAV SRL
System Manual Office Forms Manual
(FM)
Chapter: 01 First Issue: 01 Rev.No : 08
Application Form (Sea Staff) Section: 01 Date: 01/07/00 Date : 21/12/16
Page: 4 of 5 Appr. by: GM Appr.by: GM

IMO COURSES (CURSURI IMO)

NAME OF COURSE TRANING COURSES / CERTIFICATES
(NUMELE CURSULUI)
REG. STCW95 DOC. NO ISSUED EXPIRES ISSUING AUTHORITY

BASIC SAFETY TRAINING A-VI/1-1

PROFICIENCY IN SURVIVAL CRAFT A-VI/2-1
PROFICIENCY IN FAST RESCUE BOATS A-VI/2-2
ADVANCED FIRE FIGHTING A-VI/3
MEDICAL FIRST AID A-VI/4-1
MEDICAL CARE A-VI/4-2
GENERAL OPERATORS CERTIFICATE FOR GMDSS A-IV/2
HUMAN ELEMENT, LEADERSHIP AND MANAGEMENT A-III/2
(includes of BTRM / ETRM)
SHIP SECURITY OFFICER A/1.3 OR XI/2
SECURITY AWARENESS TRAINING VI/6 1,3,4,6 OR A
VI/6 1, 4, 6, 8
LICENSE UPDATE COURSE (ACTUALIZARE BREVET) includes
HIGH VOLTAGE
ECDIS GENERIC TRAINING AII/1 AII/2

ECDIS SPECIFIC TRAINING (PLEASE MENTION MODELS)

BRIDGE / ENGINE TEAM RESOURCE AND MANAGEMENT A-III/2 OR A-

VIII/2
RISK MANAGEMENT AND INCIDENT INVESTIGATION

SHIP HANDLING AND MANOUVERING SIMULATOR AII/1 AII/2 BI/12

HIGH VOLTAGE TRAINING

UNDERWATER ESCAPE TRAINING ( HUET, BOSIET)

SPARROWS CERTIFICATE (PLEASE MENTION LEVEL)

TRANSPORT AND HANDLING OF DANGEROUS, HAZARDOUS A-II/1,2 OR III/1,2

AND HARMFUL CARGOES
PREVENTION OF POLLUTION OF THE MARINE ENVIRONMENT A-I/1,2 OR III/1,2
(MARPOL 73/78)
ICE NAVIGATION

DP OPERATOR / DP MAINTENANCE CERTIFICATE

HERTM / HERTL

H2S

HLO

SLINGING AND RIGGING

TANKER FAMILIARIZATION (OIL & CHEMICAL) A-V/1, 1-7

TANKER FAMILIARIZATION (GAS)

SPECIALIZED TRAINING FOR OIL TANKER (IGS/COW) A-V/1, 8-14

SPECIALIZED TRAINING FOR CHEMICAL TANKER A-V/1, 15-21

SPECIALIZED TRAINING FOR LIQUEFIED GAS TANKER A-V/1, 22-34

 BARKLAV SRL
System Manual Office Forms Manual
(FM)
Chapter: 01 First Issue: 01 Rev.No : 08
Application Form (Sea Staff) Section: 01 Date: 01/07/00 Date : 21/12/16
Page: 5 of 5 Appr. by: GM Appr.by: GM

MEDICAL HISTORY( ISTORIC MEDICAL)

HEALTH QUESTIONNAIRE IF THE ANSWER IS YES TO ANY OF THE QUESTIONS PLEASE GIVE BELOW
CHESTIONAR MEDICAL FULL DETAILS
DACA DA, DETALIATI

HAVE YOU EVER SIGNED OFF A SHIP DUE TO MEDICAL REASONS?

DEBARCARI CAZ MEDICAL

HAVE YOU UNDERGONE ANY OPERATION IN THE PAST?

OPERATII SUFERITE IN TRECUT

HAVE YOU CONSULTED A DOCTOR DURING THE LAST 12 MONTHS DUE

TO AN ILLNESS AND/OR ACCIDENT?
BOLI SI/SAU ACCIDENTE IN ULTIMUL AN

DO YOU HAVE ANY HEALTH OR DISABILITY PROBLEMS NOW?

STAREA ACTUALA A SANATATII

ADDITIONAL INFORMATION ( SHORE BASED EXPERIENCE, ETC)

(INFORMATII ADITIONALE (EXPERIENTA IN ACTIVITATI DESFASURATE LA USCAT, ETC )

REFERENCES (REFERINTE)
NAME OF COMPANY CONTACT PERSON / POSITION CURRENT ADRESS TELEPHONE
NUMELE COMPANIEI PERSOANA DE CONTACT/ FUNCTIA DETINUTA ADRESA CURENTA TELEFON

OTHERS : HOBBIES, INTERESTS (INTERESAT DE)

I hereby declare that I do not suffer from any illnes or chronic or pre-existent medical condition and that the informations given are correct to the best of my
knowledge. I also declare that I have not been convicted or refused for entry or declared undesirable by any state. I understand that supplying false
informations or misrepresentation or omitting any facts or informations is cause for my refusal to hire or dismissal. Further, I understand that my
employment is conditioned upon a favorable health evaluation. I do hereby authorize an investigation of all statements contained in this Application.

In accordance with the requirements of the Law no. 677/2001 for the protection of persons with regards to the processing of personal data and the free
circulation of these date, amended and completed, S.C. BARKLAV S.R.L., registered at A.N.S.P.D.C.P under number 22766/2012, has the obligation to
manage in safety conditions and only for the specified purposes the personal data you provide us about yourselves, a member of your family or any other
person. The purpose of the gathering and processing of data is the submission of information about your professional training and your experience to our
contractual partners, for the purpose of working on board of foreign flag vessels or the exercising your professional activity in foreign country shipyards,
without any obligations or payments to you, following the requests received from the respective employers. The information registered are meant to be used
by the operator and will not be disclosed to other recipients than the ones mentioned above.

In accordance with the Law no. 677/2001, you have the right to access, intervene on the data, the right not to be submitted to an individual decision and the
right to resort to justice. At the same time, you have the right to oppose to the processing of the personal data about yourself and to require the erasing of the
data*. In order to exert these rights, you can submit a written, dated and signed request to S.C. BARKLAV S.R.L., Constanta county, Constanta locality, 251-
253, Mamaia boulevard, floor 3, PO 900559. In case some of the data about you are incorrect, we kindly ask you to inform us about it as soon as possible.

SIGNED (SEMNATURA) DATE (DATA) PLACE (LOCUL)