Employment Application Form

Personal Details

PHOTO

(passport size)

Position Applied For: Engine Cadet

Available From (date): 20.12.2018

Willing to accept lower rank? Yes X

No

First Name: David

Middle Name: Daniel

Last Name / Surname: Muhin

Nationality / Citizenship:

Latvian

Date of Birth: 03.05.98-10838

Place / City of Birth: Liepaja

Marital Status: Single

Gender: Female X Male

Country of Origin: Latvia

Primary/Permanent Address

Documents / Visas

Number

Place of issue

Issued

Expires

City: Liepaja

Passport

LV5485959

PMLP Liepājas Nodaļa

29.07.2016

28.07.2021

Address: Kuldigas Street 36-11

Seaman’s book (National)

0270727

Latvijas jūrnieku reģistrs Rīgā

16.11.2018

01.09.2022

Post Code: LV-3414

Seaman’s book (LBR)

Country: Latvia

US Visa C1/D

US Visa B1/B2

Nearest Airport: LPX

Schengen Visa

Mobile Tel.: +371********

Home Tel.:

Medical Certificate

VC-21905

Viecliepāja Health Medical Centre

06.11.2018

06.11.2019

E-mail: ac7vds@r.postjobfree.com

Yellow Fever

Nominee/ Next of Kin & Family Details

Full Name: Jadviga Karpova

Relations: Mother

Date of birth: 23.10.1957

Nationality: Polish

Address: Kuldigas Street 36-11

Mobile Phone: +371-*********

Post Code: LV-3414

Country/City: Latvia, Liepaja

Certificate

Number

Date of Issue

Date of Expiry

Place of issue

Basic Oil and Chemical tanker cargo operations

11/18-109

07.11.2018

Unlimited

Libau Training Center

Basic Gas tanker cargo operations

11/18-124

30.11.2018

Unlimited

Libau Training Center

Security training for seafarers

05-05/18

27.11.2018

Unlimited

Liepaja Marine College

Basic safety training

46-08/18

22.10.2018

22.10.2023

Liepaja Marine College

Sea Experience: (Last 10 years; Start the listing below with the most recent experience)

Company

Flag

Vessel Name

Type

GRT

DWT

Main Engine

BHP

Rank

Date From(dd/mm/yy)

Date To (dd/mm/yy)

Reason of Sign off (1)

(1) Reason for Sing Off - e.g. “EOC – End of Contract”, “MED – Medical Ground”, “OWN – Own request”

Please provide details of two recent employers who we may contact for references

Name of Company

Contact person

Address

Phone/E-Mail

Please answer the following questions:

Did you suffer, or presently suffer from any disease likely to render you unfit for services at sea or likely to endanger the health of other persons on board?

If yes, please provide details

YES X NO

Did you suffer any accident, which rendered you temporary and/or partially disabled?

YES X NO

Did you ever undergo psychiatric treatment?

YES X NO

Are you addicted to alcohol or drugs of any kind?

YES X NO

I hereby declare that the above facts and information are true and accurate. I understand that this data will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organization.

Place: Date: Signature:

Contact this candidate