APPLICATION FORM

Position applied for:

Date of availability:

* *******

INFORMATION

Surname Mo?s Date of 08.07.1992

birth

First name Kristaps Place of Bauska

birth

Father's Modris Citizenshi Latvia

name p

Color of Blue

eyes

Telephone 27862611 E - mail Molins8@inbox.l

v

Next of Paula Mo?a Date of 15.12.1995

kin birth

Address Bauska uzvaras iela 23-2a

Parents' Father: Modris Punka Mother: Inese Mo?a

Name Maiden name:

No. of children

under 18

Nearest airport Riga

Documents/Certificates Document No. Place Issued Date Issued Expiry Date

Passport international LV4010477 Bauska 17.07.2012 16.07.2022

Seaman's Book 0258676 Riga 26.06.2013 31.07.2015

Certificate:

Endorsement:

Basic safety training 052/12-DP Latvia 30.03.2012 unlimited

and instruction

Fire-fighting Leader 052/12-DP LATVIA 30.03.2012 UNLIMITED

Proficiency in survival

craft & rescue boats

Medical AID/CARE

Hazardous Cargoes

ARPA-Certificate

Radar Observer

GMDSS Certificate

Endorsement

Ship safety officer

Ship security officer

Bridge team and Resource

management

ECDIS

Yellow Fever Certificate

Health certificate 230/6 VIA UNA 28.06.2013 28.06.2015

MARITIME

POLYCLINIC

Other:

LAST 5 YEARS SEA SERVICE DATA:

BUILT VESSEL'S NAME TYPE

( SEAFARER'S SIGNATURE )

ENGLISH TEST:

PROFESSIONAL TEST:

ADD. INFORMATION:

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