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    Seafarer'S Application Form: Rusam Maritime Agency LTD

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    maks
    This document is a seafarer's application form for Maksim Alexsandrovich Kalinin, a Russian national seeking employment as an Able Bodied seaman. It includes his personal details, education history, medical certifications, passport and visa information, language skills, and records of previous sea service over the past 7 years working for various shipping companies in roles including deck cadet, ordinary seaman, and able bodied seaman. By signing the form, he consents to his personal data being processed and stored to assist with employment opportunities.

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    © All Rights Reserved
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    Seafarer'S Application Form: Rusam Maritime Agency LTD

    Uploaded by

    maks
    240 views2 pages
    This document is a seafarer's application form for Maksim Alexsandrovich Kalinin, a Russian national seeking employment as an Able Bodied seaman. It includes his personal details, education history, medical certifications, passport and visa information, language skills, and records of previous sea service over the past 7 years working for various shipping companies in roles including deck cadet, ordinary seaman, and able bodied seaman. By signing the form, he consents to his personal data being processed and stored to assist with employment opportunities.

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    APP_BLK_2020.doc

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    This document is a seafarer's application form for Maksim Alexsandrovich Kalinin, a Russian national seeking employment as an Able Bodied seaman. It includes his personal details, education history, medical certifications, passport and visa information, language skills, and records of previous sea service over the past 7 years working for various shipping companies in roles including deck cadet, ordinary seaman, and able bodied seaman. By signing the form, he consents to his personal data being processed and stored to assist with employment opportunities.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    240 views2 pages

    Seafarer'S Application Form: Rusam Maritime Agency LTD

    Uploaded by

    maks
    This document is a seafarer's application form for Maksim Alexsandrovich Kalinin, a Russian national seeking employment as an Able Bodied seaman. It includes his personal details, education history, medical certifications, passport and visa information, language skills, and records of previous sea service over the past 7 years working for various shipping companies in roles including deck cadet, ordinary seaman, and able bodied seaman. By signing the form, he consents to his personal data being processed and stored to assist with employment opportunities.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    You are on page 1of 2

    RUSAM MARITIME AGENCY LTD

    (Company certified for compliance with ISO 9001:2015 & MLC 2006)
    50 Zoologicheskaya str., Kaliningrad, Russia
    Tel. 8 (4012) 916-808 / 916-769/ 916-864/ 988-307
    E-mail: cv@rusamagency.ru rusam@rusamagency.ru
    www.rusamagency.ru
    SEAFARER’S APPLICATION FORM (Form no.1 , Ver.9)
    Name in full (First, Middle, Last) : Maksim Alexsandrovich Rank : AB
    Kalinin
    Date & place of birth: 23.04.1992 Nationality: Russia
    Marital Single Married Divorced Widower Nearest Airport ( City / Country) :
    status: + LED/ARH

    Permanent Address ( full style): Next of kin (surname, name, date of birth): Children (surname, name, date of birth):
    1.
    Tel: Relationship: mother
    Mob: +79539388883 Address: pr.Nikolskii 37 ap 28 2.
    e-mail: makscalifornia@icloud.com Mob: +79021931331
    skype: californiaeg e-mail: kalinina720@yandex.ru 3.
    Hair / eyes (colour) :Brown/blue Height (m): Weight (kg)/ BMI: Safety shoes size: Safety overall size:
    190 81 45 52
    Education (name & city of educational institution, dates of entry / graduation and degree): satady to navigator

    YELLOW FEVER VACCINATION CERTIFICATE :


    Country of issue Number: Date issued: Place issued: Expiry Date: Remarks
    RUSSIA 04.02.2016 Arkhangelsk 01.01.2026
    LICENCE INFORMATION (Certificate of Competency/Proficiency):
    Country: Grade of Licence: Number: Date issued: Place issued: Expiry Date:
    National Licence

    Other Flag License

    OTHER CERTIFICATES AND ENDORSEMENT INFORMATION:


    Certificate/Endorsement STCW Regulation No Number /Type Date issued: Place issued: Expiry Date:

    GMDSS ( GOC / ROC)


    ARPA / Radar
    ECDIS
    Bridge / Engine Team
    Ship Security Officer
    ISPS 0235970 25.11.2015 Russia 25.11.2020
    Basic Safety Training 0809637 06.09.2017 Russia 06.09.2022
    First Aid // Medical care 021071 10.12.2019 Russia 10.12.2020
    Survival craft & rescue
    0622525 06.09.2017 Russia 06.09.2022
    boats
    Advanced Fire Fighting 1117722 10.12.2018 Russia 10.12.2023
    SEAMAN’S BOOK, SEAFARER’S ID & PASSPORT INFORMATION:
    Seafarer’s ID No: Place & Date Issued: Expiry Date: Travel Passport No: Place & Date Issued: Expiry Date:
    0403015 Russia/04.05.2018 03.05.2023 72 3133606 Russia/19.02.2013 19.02.2023
    Other Flag Place & Date Issued: Expiry Date: National Seaman’s Place & Date Issued: Expiry Date:
    Seaman’s Book No: Book No:
    MK0176547 13.05.2013 ∞
    VISA INFORMATION:
    Visa: Type: Valid Until: Remarks:
    USA visa 20183249550005 C1/D 19.11.2020
    Schengen Visa 004021924 C 30.01.2021
    LANGUAGE INFORMATION:
    Good Satisfactory Poor Remarks ( Marlins Test (%) , etc.)
    English +
    Page 1 of 2
    RUSAM MARITIME AGENCY LTD
    RECORDS OF PREVIOUS SEA SERVICE ( for previous 7 years)
    Vessel’s Name / Flag IMO Number DWT / Vessel’s Rank From To Months Company
    year of build Type and Model Type / Deck (date-month- (date-month- (Shipowner /Technical Manager/
    year) year)
    of M.E., kW Cranes Crewing Agency)
    Wilson Gijon/1993 Barbados 9056038 3689/B&W/1470 General Cargo Deck cadet 29.05.2013 05.10.2013 Wilson Shipping
    Wilson Tana/1977 Malta 7616224 7174/Mitsubishi/3812 General Cargo OS 05.05.2014 06.08.2014 Wilson Shipping
    m/v Lucina/2003 Curacao 9255622 9857/MAK/3840 General Cargo OS 11.03.2015 12.06.2015 FriedabShipping
    Clipper Tenacious/2007 Bagamas 9320348 30634/B&W/6480 Bulk Carrier OS 07.02.2016 06.04.2016 C;ipper /Dania
    Clipper Lasco/2004 Singapore 9320348 28200/ B&W/5860 Bulk Carrier OS 02.02.2017 26.06.2017 C;ipper /Dania
    Tor/1964 Russia 5418197 1024/4x2530 Icebreaker AB 04.09.2018 10.10.2018 Rosmorport
    Express France/2010 44080/wartsila 7rt-
    Malta 9443035 Container ship OS 14.12.2018 21.01.2019 Danaus
    flex82c/31640
    Kolguev/1971 Russia

    REMARKS (Availability for service; Dry Dock experience; other languages; mix crew experience; other, etc.): MIX CREW MOSTLY PHILLIPINO SINCE 2000.

    I hereby confirm that all the information provided by me in this form is true and correct.
    Date:
    Signature of Seafarer:

    References:
    Company (Crewing or Shipowner) / Contact person (Superintendent, Manager, Captain, Chief Engineer or other person/ Telephone number):
    _______________________________________________________________________
    Источник, из которого Вы узнали о нашей Компании (интернет-сайты, реклама, другие моряки, и др.):__ _____________________________________
    Уважаемые Моряки, РУСАМ не является работодателем; мы рассматриваем Вашу анкету как запрос на содействие по трудоустройству. Заполнение анкеты не является гарантией
    или обязательством по трудоустройству, а служит цели рассмотрения Вашей кандидатуры
    Dear Seafarers , RUSAM is not employer. We're considering Your application as request for assistance to employment. Filling of application is not guarantee of employment, it's needed for consideration You as a
    candidate.
    С автоматической обработкой моих персональных данных, указанных в анкете, включая их передачу третьим лицам на территории РФ и за ее пределами, их хранением в целях
    трудоустройства, в соответствии с Федеральным Законом РФ № 152 от 27.07.2006 г. СОГЛАСЕН.
    Подтверждаю, что мои персональные данные, указанные в анкете, являются общедоступными.
    I hereby give my consent to automatic processing of the information contained herein, including its transfer to third parties in the territory of the Russian Federation and abroad, as well as its storage for the purposes
    of employment assistance, in accordance with the Federal Law RF No 152 dated 27-Jul-2006.
    I hereby confirm that my personal details contained herein are for public use.

    Signature of Seafarer (подпись Mоряка): Date (дата): Page 2 of 2

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