OMEGA SHIPPING AND TRADING LTD. RECENT www.omegacrewing.ro PHOTO email :office@omegacrewing.

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Application For Employment As: Date Available for Joining: LLLLLLLLLL PERSONAL DETAILS: Surname: First Name: Middle Name: CONTACT DETAILS: Permanent. Address: Address: No.: Telephone Telephone No.: Mob.Tel. Nearest International Airports: DOCUMENTS: Travel Passport No. Date of Issue: Seamans Book No. of Issue: Date USA visa Other visa

Rank :

Date of Birth: Place of Birth: Nationality: Religion:

Fax. No.: E-mail: @

Place of Issue: Date of Expiry: Place of Issue: Date of Expiry: Issued: Issued: Issued: Name of spouse: Relationship

Valid till: Valid till: Valid till:

FAMILY DETAILS : Marital Status: Name of children ( under 18 years old )

Age

EMERGENCY INFORMATION: Next of Kin: Home Tel. No.: Tel. No.: Relationship: Office Address: MEDICAL INFORMATION: Medical examination: Clinic: Issued: Drag and alcohol test: Clinic: Issued: VACCINATIONS (valid for duration of contract). Date of vaccination: Cholera: Yellow Fever: Tetanus: Weight: kg. Clothes size: Height: cm. Head size: Shoes size: cm. LICENCE PARTICULARS Grade National Licence Tanker endorsement Crude Oil Liquid chemical Liquefied gas Panamanian endorsement: Liberian endorsement: Bahamian endorsement: Other: S. T. C. W. COURSES Radar observation and plotting simulator Automatic Radar Plotting Aids G.M.D.S.S. cm. cm. Eyes colour: Hairs colour: Skins colour: Place of Issue

Valid till: Valid till: Hepatitis B:

Cert No

Date of Issue

Date Expires

Personnel Survival Techniques Personal Safety and Social Responsibilities Fire prevention and Fire-fighting Elementary First Aid Medical First Aid (Table A-VI/4-1) Advanced Medical Care (Table A-VI/1, A-VI/4) Advanced Fire fighting Proficiency in survival craft, rescue boats Fast Rescue Boat Leader Oil tanker familiarization course The specialized oil-tanker training programme including: Crude oil washing operations / Inert gas system) Chemical tanker familiarization course The specialized chemical tanker training programme Carriage of dangerous and hazardous substances Liquefied gas tanker certificate Prevention and Fighting Marine Pollution Manoeuvring & Ship handling (Section AII/I) ROP/ARPA Ship Security Officer Others courses Professional Qualifications ESTABLISHMENT Name (Nautical College / Institute)

Date Attended

Basic Academic QUALIFICATIONS (Diploma / License)

Date Passed

SHIP EXPERIENCE (Tick Boxes which apply ( X ) CARGO OFFSHORE PASSENGER Bulk Carrier AHTS Cruise Ship Car Carrier Buoy Tender Fast Ferry (inc CAT) Container Ship Cable Layer Passenger ship Ro-Ro Drill / Rig / SemiPassenger / Ro-Ro sub - Dive Support Gen Cargo DSV Timber Carrier Standby Reefer Supply Cement Carrier Seismic Survey OBO Tug MAIN ENGINE EXPERIENCE (Engineers only) (Tick Boxes which appl ( X ) Allen Doxford Industrie-diesel British Polar Caterpillar Lister Bukh General Motors MAK Burmeister & Wain Gotaverken MAN Daihatsu Greena diesel Mirrlees Blackstone Dorman Hyundai Mitsui Deutz Hedamora Mitsubishi Experience with Multinational Crew: Nationality: Initial Interview Date: Interviewed by: Level of English Appearance: Interviewer Notes: Fleet Personnel Department Notes:

TANKERS Chemical Oil tanker FPSO LNG tanker LPG tanker Product tanker VLCC / ULCC

GENERAL Dredger Fishing Vessel Hopper Barge Research Vessel Naval auxiliary Royal Navy Yacht

Paxman Petter Pielstick Rolls Royce Ruston Scania Shkoda

Stork Stork Werspoor Sulzer Wartsila -Vasa Yanmar Volvo-Penta Other Months: Result: Attitude:

DETAILS OF PREVIOUS SEA SERVICE previous Sea - Service (employment list for the last 5 years) Name of Vessel Flag Type of Vessel GRT Type of B.H.P Rank Engine

Period of Service

Name of Owners or other remarks

I hereby declare to accept Drug and Alcohol test if they are requested by Owner before joining his vessels I hereby declare the facts in this application are true to the best of my knowledge. I also agree that any misrepresentation or withholding on any information will be a ground,for denial of my application and termination of my employment, if already employed. I hereby declare I can communicate adequately in the English language to perform,the job and safety requirements for position requested. FOR OMEGA SHIPPING AND TRADING OFFICE USE ONLY N.B. S.C. OMEGA SHIPPING AND TRADING prelucreaz datele cu caracter personal furnizate de dumneavoastr prin acest document n scopul prezentarii candidaturii dvs pentru o posibila angajare. Datele vor fi dezvluite numai clientior nostrii, posibili angajatori. Pe viitor, aceste date ne permit s v inem la curent cu activitatea noastr, precum si cu ulterioare solicitari de angajare . n cazul n care nu dorii aceasta, nu va vom putea lua in considerare aplicatia si nu va vom inregistra in baza noastra de date. Conform Legii nr. 677/2001, beneficiai de dreptul de acces, de intervenie asupra datelor, dreptul de a nu fi supus unei decizii individuale. Avei dreptul s v opunei inregistrarii datelor personale care v privesc i s solicitai tergerea lor din baza noastra de date. Pentru exercitarea acestor drepturi, v putei adresa cu o cerere scris, datat i semnat la sediul nostru N.B. S.C. OMEGA SHIPPING AND TRADING process personal data supplied by you through this document to present your application for possible employment. Data will be disclosed only to our clients, potential employers. In the future, these data allow us to keep you abreast of our activities, as well as future employment demands. If you do not want it, we can not consider the application and we will not record in our database. According to Law no. 677/2001, have the right to access the data on intervention, the right not to be subject to individual decisions. You are entitled to oppose registration of your personal data and request deletion from our database. To exercise these rights, you can submit a written request, dated and signed in our office APLICANTS SIGNATURE : APROVED BY : CREWING CO-ORDINATOR DATE :