Fratelli d’Amico Armatori S.p.A.

ROMA Crew Application Form IP 03 Form 02a

Rev. 0 Date 23/08/10 Pag. 1

[PLEASE USE CAPITAL OR UPPERCASE LETTERS TO COMPLETE THIS FORM]

Individual’s Code Number

1. Personal Data
First Name Middle Name (s) Last Name / Surname

AFFIX YOUR
RECENT
Nationality (or current Country of Origin Date of Birth: Place / City of Birth PHOTOGRAPH
Citizenship ) __ / __ / __ HERE
(PASSPORT SIZE)
(DD / MM / YY)

Marital Status1: Gender : Male Religion:

Female
1
Select from : ●Single ●Married ●Divorced ●Common Law Partner ●Widowed ●Separated

Rank applied for: Willing to accept lower rank? Yes Available From (date): __ / __ / __
No (DD / MM / YY)

Primary / Permanent Address: Alternative / Temporary Address: Until: __ / __ / __

(DD / MM / YY)

City: Post Code: City: Post Code:

State: Country : State: Country:
Nearest Airport Home Tel: Phone:
Mobile Tel. Fax: Email:
Contact Method : Email Fax Mobile Phone Home Phone Post

Collar: ______cm Chest: ______cm Waist: ______cm Inside Leg: ______cm Cap: ______cm
Specify size as S, M, L, XL, XXL for : Sweater size: Boilersuit size: Shoe size:

2. Personal ID / Documents / Visa

Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 2
 Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 3

Type of Document / ID 1 Country of Issue No. Date of Issue Issued at (Place) Valid Until
(DD / MM / YY) (DD / MM / YY)
Seaman’s Book (National)
Passport
US Visa C1/D
National Seaman ID
Yellow fever
Australia MCV

GIVE TAX INFORMATION BELOW ONLY IF REQUESTED TO DO SO

Social Security Personal Tax (or Fiscal Code)
Number: Issuing Country: Number: Issuing Country:

1
Select as applicable: ●Passport ●Seamans Book ●Seaman Passport ●Seafarers’ Identity Document ●Registration Book ●National ID Card ●PAG-IBIG
Housing Insurance ●Health Insurance ●Overseas Emp Cert ●PHL Card ●Pension Fund ●Provident Trust ●Professional Organisation ●Driving Licence ●Visa
●Vaccination ●Yellow Fever.
 Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 4

3. Nominee / Next of Kin & Family Details

Full Name of Nominee for compensation in case of fatality: Relationship1 Gender : Male
Nationality :
_______________________________ ________ Female
Address:
City: Post Code: Country:
Email: Tel: Mobile:
1
Select From : ●Spouse ●Partner ●Child ●Parent ●Grand Parent ●Other Relative (Please Specify)

Family Data:
Relationship First Name Last Name Date of Birth Place Fiscal Code
2
Spouse / Partner
Child M F
Child M F
Child M F
Child M F
Child M F
Indicate type of valid visa3 USA Canada Australia Schengen UK Other: __________________________
2 3
Strike out inapplicable item Please consider period on board

4. STCW-1978 (amended 1995) Compliant Certificates / Courses and Other Qualifications: -

(Add separate sheet if data exceeds space available.)
Country of Date of Issue Date of Expiry
Description of Cert / Course Number Place of Issue Issuing Authority / Body
Issue (dd-mm-yy) (dd-mm-yy)

(A) Reg I
Personal Training Record Reg I/14
Medical Fitness Cert Reg I/9

(B) Reg VI / 1 – Basic Safety Training

Personal Survival Techniques
Elementary/Medical First Aid
Fire Fighting & Fire Prevention
Personal Safety & Social Resp.

(C) Reg VI / 2 –4 Additional Training

Prof. in Survival Craft & Rescue Boat
Fast Rescue Boats
Advanced Fire Fighting
Medical Care (Master / C/O)

(D) Reg II / 1-4, III / 1-4 Officers Certificate of Competency & Ratings Watch-keeping Certificate (including flag state
endorsements)
4

4
Enter here actual description given in the Competency Certificate / Watchkeeping Certificate held by you
(E) Other mandatory/recommended Certificates / Courses – (as applicable)
Radar Simulator (Basic)
ARPA (Reg II/1 + Solas)
English Language Test/Course
Bridge Team / Resource Mgmnt
Hazmat (US – 49CFR)
Shiphandling Simulator
Ship Security Officer (SSO)
ECDIS
ARPA SAR (Master / C/O)
 Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 5

Country of Date of Issue Date of Expiry

Description of Cert / Course Number Place of Issue Issuing Authority / Body
Issue (dd-mm-yy) (dd-mm-yy)
(F) GMDSS Certificates (including flag state endorsements)
GMDSS (Main Issuing Authority)
Endors. GMDSS (Flag State)

(G) Reg V / 1 – Special Requirement for Tankers

Level1:Asst Country of Date of Issue Date of Expiry Issuing
Description Number Place of Issue
Level2:Incharge Issue (dd-mm-yy) (dd-mm-yy) Authority / Body
Endorsement – Oil
Endorsement – Chem I/II
Endorsement – Chem III
Endorsement – Gas
Tanker Familiarisation Para 1
Tanker Safety (Oil) Para 2
Tanker Safety (Chemical) Para 2
Tanker Safety (Gas) Para 2

(H) V/2 and V/3 – Other special training

Country of Date of Issue
Description For Vsl Type (1) Number Place of Issue Issuing Authority / Body
Issue (dd-mm-yy)
Crisis Mgmnt & Human Behaviour
Cargo Handling & Hull Integrity
Crew Safety Training
Environment Protection Training
Risk Assessment
Incident Investigation

5. Sea Experience : (Last 5 years; Start the listing below with the most recent experience)
Date From Date To
Company Flag & Vessel Name Type (1) GRT DWT Main Engine (2) BHP Rank
dd/mm/yy dd/mm/yy

(1)
Use only the following abbreviations for vsl types:
BC Bulk Carrier FSO FloatingStorageOffldg OBO Ore/Bulk/OilCarrier RIG OffShore Oil Rig TNB Tanker(Bitumen)
 Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 6

CON Cellular Container FPSO FloatgProdStorOffldg OSV OffShore Supply Vsl RFG Reefer Vessel TNC Tanker(Crude)
CHM Chem Carrier IMO I-II LNG LNG Carrier OTH Other R/R Ro/Ro Carrier TNP Tanker(Products)
CH3 Chem Carrier IMO III LPG LPG Carrier PAS Passenger Ship SRV Survey Vessel TNS Tanker(Storage)
FSV Fishing Vessel NVL Naval Ship PRR RoRo-Pax TUG Tug TNV Tanker(VLCC/ULCC)
(2)
Engineers to give make/model of engines, e.g. “MAN 14V52/55A”; “SULZER 5RTA58”; etc.
 Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 7

6. Medical History:

All previous illnesses other than minor afflictions should be stated below or updated. If not previously disclosed,
the Company is entitled to refuse any reimbursement of medical costs, claim for treatment or for any other insured
benefits.
(A) Have you ever signed off a ship due to medical reasons? Yes No
If yes, please provide following details (If space is insufficient, attach additional
sheets) :
Name of vessel Date of occurrence Place of occurrence

Brief description of illness/injury/accident:

(B) Have you undergone any operation or special medical treatment in the past? Yes No
If yes, please provide following details:
Details of operation Date Period of disability Present condition

(C) For what illnesses or accidents have you consulted a doctor during the last 12
months?
Details of illness / accident Date Therapy/Treatment

(D) Please give details of any health or disability problem (including also eventual allergies)
Details:

7. Bank Details: Other Details: (if any)

Bank Name
Address

Account Name
Account No.
Sort Code

8. General
(A) Have you ever been denied a foreign visa? Yes No
If yes, state which country and reason (if known)
(B) Have you been the subject of a court of enquiry or involved in a maritime accident? Yes No
If yes, please attach details
(C) Give details below of two recent employers who we may contact for references:
Reference 1 Reference 2
Name of Company
Name of person to contact
Address

Country
Telephone

I hereby declare that the above, including Medical History, is true. I further consent to the holding and processing by your Company of personal data about me (including where
appropriate data concerning racial or ethnic origin, religious beliefs, membership of a trade union, physical or mental health or condition, commission or alleged commission of an
offence and the proceedings and the outcome of any proceedings relating thereto) for all purposes related to my application for employment on board vessels Owned and managed by
the Company. I understand that this data will be stored in your databases in relation to my actual or potential employment.

Place: …………………….............…… Date: ……………………….. Signature: .…………………………………………………………..

 Fratelli d’Amico Armatori S.p.A.
ROMA Crew Application Form IP 03 Form 02a
Rev. 0 Date 23/08/10 Pag. 8

FOR OFFICE USE ONLY: All informations listed in the present form will be used in compliance with
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