Ordinary Seaman

Employment Application Form

Personal Details

Position Applied For: Ordinary Seaman (OS)

Available From (date): End of January, 2016

Willing to accept lower rank? Yes

No

First Name: Raivis

Middle Name:-

Last Name / Surname: Kalbenoks

Nationality / Citizenship: Latvian

Date of Birth: 13.05.1991

Place / City of Birth: Riga, Latvia

Marital Status: Married

Gender: Female Male

Country of Origin: Latvia

Primary/Permanent Address

Documents / Visas

Number

Place of issue

Issued

Expires

City: Riga

Passport

LV3929677

PMLP Rigas 1. Nodala

29.02.2012.

27.02.2017.

Address: Ieriku str. 12-4

Seaman’s book (National)

0256251

Latvijas Jurnieku Registrs Riga

25.06.2012.

25.06.2017.

Post Code: LV-1084

Seaman’s book (LBR)

Country: Latvia

US Visa C1/D

US Visa B1/B2

-

Nearest Airport: RIX

Schengen Visa

Not Required – EU Citizen

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

Home Tel.:

Medical Fitness Certificate

010120

Kherson Center Medical Exams – Kherson, Ukraine

05.11.2015

05.11.2016

E-mail: *.*********@*****.***

Yellow Fever

Diplomatic Service Medical Center, Riga

27.06.2012

27.06.2022.

Nominee / Next of Kin & Family Details

Full Name: Lidija Kalbenoka

Relationship Mother

Gender: Female

Male

Date / Place of Birth ?/Riga

Nationality Latvian

Address: Ieriku st. 12-4

City: Riga

Home Tel.:

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

Post Code: LV-1084

Country: Latvia

Certificate of Competence (including flag state endorsement)

Grade

Number

Date of Issue

Country of Issue

Date of Expiry

COC (National) (Second Class Seaman)

42/12

04.02.2016

Ukraine

Unlimited

COC End. (National)

COC End.(LBR)

COC End.(PRT)

GMDSS Certificates (including flag state endorsement) GOC / ROC

Number

Date of Issue

Country of Issue

Date of Expiry

GMDSS COC (National)

GMDSS End. (National)

GMDSS End. (PRT)

Certificates and trainings attended (where applicable)

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 for Sign off (1)

Hanza Marine Management

Marshal Islands

Gas Puffer

LPG

5752

4530kw

Messman

16.07.13.

04.12.13.

EOC

Anglo Eastern

Curacao

Talisman

Heavy Lift Carrier

42.515

18.175

Messman

05.07.12.

09.09.12.

MED

VIK

Aleksandrovka

Dry-cargo

993

794

150

Sailor Intern

25.08.2015

27.10.2015

EOC

(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

Hanza Marine Management (Riga)

Anglo Eastern (Riga)

Contact person

Address

6 Pils. Street, Riga LV-1050, Latvia

12, citadeles str., Riga, Latvia, LV1010

Phone/E-Mail

+371-*****-***; +371-*****-***

+371(6)7320963

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 NO

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

YES NO

Did you ever undergo psychiatric treatment?

YES NO

Are you addicted to alcohol or drugs of any kind?

YES 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: Riga, Latvia Date: 16.02.2016. Signature: Raivis Kalbenoks

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