Ordinary Seaman

APPLICATION FORM

PHOTO

Position applied for: O\S Date available: 15-02-2016

* ******** *******

Name: (Last Name): Sobolewski (First names): Rafał Date/place of birth: 10-05-1990 Gdańsk Nationality: Poland Permanent address: Street: Zawadzkiego 3/35

Post code: 84-230 City: Rumia

Mailing address: Street: 3-Maja 25/94

Post code: 80-802 City: Gdańsk

@ E-mail: acs4p6@r.postjobfree.com

N

o.:

No.:

Mobile phone: 501765026 Fax No.:

Height (cm): 175 Weight (kg): 60

Colour of eyes: blue Colour of hair: Brown

Marital status: Single Father’s name: Andrzej

Nearest airport: Gdańsk

2 Education Background

School / College From To Highest Qualification Attained Akademia Marynarki Wojennej 01-10-2013

3 Identity documents

DOCUMENT Country Number Issued date Expiry date Place Passport: National AT 294****-**-**-**** 07-04-2018 Gdynia Seaman’s book: National 026****-**-**-**** Gdynia

Other:

Do you hold a US Visa ‘C1/D’?

YES NO Valid until:

Have you been rejected for any visa applied for? YES NO If YES, please state the country and reasons

4 Next of kin

Name: (Last Name): Sobolewska

(First Names) : Iwona

Relationship: Mother

Address: 3-Maja 25/94

Post code: 80-802 City: Gdańsk

No.: Home: Mob. 502610351

5 Health Certificates

Issue date Expiry date

International Health Cert. 23-05-2014 23-05-2016

Vaccination against Yellow fever

Drug & Alcohol test

6 Certificates of competency

Class / Grade Number Place / Country Issued Issue date Expire date O\S

GUM-131**-******-

6312/2015

GDYNIA, POLAND 29-12-2015

VALID

INDEFINITELY

7

Courses attended and certificates obtained

Course name Number Issue date Expire date Issued by Issued at Basic Fire Fighting

GUM-542*-******-

22929/2014

15-04-2014 10-04-2019

Maritime

Office

Gdynia

Advance Fire Fighting

Elementary First Aid

GUM-542*-******-

22929/2014

15-04-2014 10-04-2019

Maritime

Office

Gdynia

Medical First Aid

Medical Course

Personal Survival Techniques

GUM-542*-******-

22929/2014

15-04-2014 10-04-2019

Maritime

Office

Gdynia

Personal Safety & Social Responsibility

GUM-542*-******-

22929/2014

15-04-2014 10-04-2019

Maritime

Office

Gdynia

Proficiency In Survival Craft

GMDSS

ARPA

Radar

Ship Security Officer Course

Other:

Proficiency in Security-awereness

GUM-135*-******-

20069/2014

21-03-2014

Maritime

Office

Gdynia

Proficiency for seafarers with

designated security duties

GUM-135*-******-

19983/2014

21-03-2014

Maritime

Office

Gdynia

8

Languages

Fluent Very good Good Poor Satisfactory

English

9

Bank account information (optional)

Bank Name:

Address:

Account No.:

Swift code:

Owner name:

Owner address:

10

References (Please give the name and address of your current or immediate past employer) Name of company:

Name of person to contact:

Address:

No.:

10a

References

Name of company:

Name of person to contact:

Address:

No.:

11

9

Sea service

Record of previous service

(Please give a full record starting with the last vessel on which you served) VESSEL NAME FLAG OWNER NAME

VESSEL

TYPE

RANK

SIGNED

ON

SIGNED

OFF

ME TYPE GRT/BHP

AKUL POLAND

"WUŻ" Port

And Maritime

Services Ltd

Sp. z o.o.

TUG

DECK

CADET

01-08-

2014

30-09-

2014

Ulstein

Bergen

385

GREEN MUSIC BAHAMAS

GREEN

MANAGEMENT

REFRIGATED

CARGO

DECK

CADET

13-07-

2015

07-08-

2015

5103

## Required for engineer applicants only

12 Declaration

I hereby declare that the above particulars are true and authorise you to contact the referees listed above. W związku z Ustawą z dnia 29.08.1997 r. O ochronie danych osobowych” niniejszym wyrażam zgodę na przechowywanie i przetwarzanie moich danych osobowych złożonych w firmie Green Management Sp. z o.o. Jednocześnie zgadzam się na udostępnienie w/w danych armatorowi zagranicznemu w ramach działań, mających na celu moje zatrudnienie. Poinformowano mnie, iż mam prawo wglądu i poprawiania danych.

In connection with the Law of 29.08.1997 "On Protection of Personal Data" herewith I do agree to the storage and processing my personal data submitted in the company Green Management Sp. z o. o. At the same time I agree to share same with foreign ship owner under the measures aimed at my employment. I am ensured that I have the right to inspect and correct the data. Sobolewski

Date:

08-07-2015

Signature

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