APPLICATION

APPLICATION FOR POSITION AS

*/***, ****** ********

OTHER POSITION (IF ANY)

*/***

1. PERSONAL DETAILS

TITLE MR/MRS/MISS

MR

SEX

MALE

FEMALE

SURNAME

LIPIEJKO

FIRST NAME

SEBASTIAN

OTHERS NAMES

-

DATE OF BIRTH

1990-11-07

PLACE OF BIRTH

BARTOSZYCE

NATIONALITY

POLISH

MARITAL STATUS

SINGLE

COLOUR OF EYES

GREY

COLOUR OF HAIR

BLOND

MOTHER’S NAME

MARIA

FATHER’S NAME

ZBIGNIEW

MOTHER’S MAIDEN NAME

STACH

HEIGHT (CM)

180

WEIGHT (KG)

80

NEARST INTERNATIONAL AIRPORT:

GDANSK

2. ADDRESS

ADDRESS (TEMP.) FROM/TO:

NO & STREET

PARTYZANTOW 5A

NO & STREET

CITY

BARTOSZYCE

CITY

POST CODE

11-200

POST CODE

COUNTRY

POLAND

COUNTRY

TEL. NO.

TEL. NO.

MOBILE

+486********

MOBILE

E-MAIL

acyie1@r.postjobfree.com

E-MAIL

FAX

FAX

3. NEXT OF KIN

FULL NAME

ZBGINIEW LIPIEJKO

RELATIONSHIP

FATHER

ADDRESS

PARTYZANTOW 5A

CITY

BARTOSZYCE

COUNTRY

POLAND

TEL. NO.

+486********

MOBILE

FAX NO.

4. CHILDREN

NAME OF CHILD

DATE OF BIRTH

SEX

M

F

M

F

M

F

5. TRAVEL DOCUMENTS

TYPE

DOCUMENT NO.

ISS.DATE

EXP. DATE

ISS. BY (AUTHORITY)

PLACE OF ISSUE

PASSPORT

EL 2033281

2017-01-13

2027-01-13

WOJEWODA POMORSKI

GDANSK

SEAMAN BOOK

0264514

2013-08-02

GDYNIA

OTHER SEAMAN BOOK

US C1/D VISA

OTHER VISAS

6. BANK ACCOUNT INFORMATION

BANK NAME

BRANCH

BANK ADDRESS

CITY

COUNTRY

SORT CODE

ACCOUNT NO

BANK SWIFT CODE

BANK TEL. NO

ACCOUNT OWNER’S NAME

ACCOUNT OWNER’S ADDRESS

7. EDUCATION

SCHOOL NAME

GDYNIA MARITIME UNIVERSITY

ENGIEER

FROM

2010

TO

2015

SCHOOL NAME

FROM

TO

8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY

CERTIFICATE NAME

NUMBER

ISSUE DATE

EXPIRY DATE

ISSUED BY (AUTHORITY)

ISSUED AT

COC WIPER

GUM-13164-125149-5622/2013

2013-12-27

GDYNIA

COC ENGINEER OFFICER IN CHARGE OF WATCH

GUM-131**-******-***/2017

2017-01-25

2020-03-13

GDYNIA

DANGEROUS CARGO ENDORSEMENT

NUMBER

ISSUE DATE

EXPIRY DATE

PETROLEUM

CHEMICAL

GAS

9. LANGUAGES

ENGLISH

FLUENT

GOOD

FAIR

POOR

GERMAN

FLUENT

GOOD

FAIR

POOR

FRANCH

FLUENT

GOOD

FAIR

POOR

SPANISH

FLUENT

GOOD

FAIR

POOR

ITALIAN

FLUENT

GOOD

FAIR

POOR

RUSSIAN

FLUENT

GOOD

FAIR

POOR

MARLIN’S TEST / LEVEL

ISSUED DATE

RESULT %

ISSUED BY (AUTHORITY)

ISSUED AT

10. VACCINATIONS

NAME

ISSUE DATE

EXPIRY DATE

ISSUED BY (AUTHORITY)

ISSUED AT

YELLOW FEVER

2014-04-10

2024-03-31

GDYNIA

CHOLERA

TYPHOID

TETANUS

HEPATITIS A

POLIO

11. SAFETY CLOTHING

BOILERSUIT SIZE

M

BOOTS SIZE

45

12. MARINE COURSES

COURSE NAME

NUMBER

ISSUE DATE

EXPIRY DATE

ISSUED BY (AUTHORITY)

ISSUED AT

PERSONAL SURVIVAL

GUM-5425-125149-8830/2013

2013-05-29

2018-05-11

GDYNIA

BASIC FIRE FIGHTING

GUM-5425-125149-8830/2013

2013-05-29

2018-05-11

GDYNIA

ADV. FIRE FIGHTING

GUM-1315-125149-15011/2015

2015-05-28

2015-05-28

GDYNIA

ELEMENTARY FIRST AID

GUM-5425-125149-8830/2013

2013-05-29

2018-05-11

GDYNIA

MEDICAL FIRST AID

GUM-5421-125149-14570/2015

2015-05-26

GDYNIA

MEDICAL CARE

PERS. SAFETY & SOC. RESP.

GUM-5425-125149-8830/2013

2013-05-29

2018-05-11

GDYNIA

PROF. IN SURVIVAL CRAFT & RESCUE BOATS

GUM-1319-125149-14558/2015

2015-05-26

2020-05-25

GDYNIA

FAST RESCUE CRAFT

TRANING IN ENGINE ROOM RESOURCE MANAGEMENT

GUM-1333-125149-84975/2016

2016-12-28

GDYNIA

ENGINE ROOM SIMULATOR TRAINING

13/451/2016

2016-12-29

GDYNIA

RADAR OBSERVATION

HAZMAT

BASIC TANKER FAMILIARIZATION - OIL

GUM-1337-125149-20812/2014

2014-03-27

GDYNIA

ADVANCED OIL TANKER

BASIC TANKER FAMILIARIZATION - CHEMICAL

GUM-1337-125149-20812/2014

2014-03-27

GDYNIA

ADVANCED CHEM. TANKER

BASIC TANKER FAMILIARIZATION - GAS

GUM-1303-125149-20831/2014

2014-03-27

GDYNIA

ADVANCED GAS TANKER

CRUDE OIL WASHING

INERT GAS PLANT

ISM CODE

SHIP SECURITY OFFICER

COP IN SECURITY AWARENESS

GUM-1350-125149-11428/2014

2014-02-05

GDYNIA

COP FOR SEAFARERS WITH DESIGNATED SECURITY DUTIES

GUM-135*-******-***/2017

2017-01-03

GDYNIA

BRIDGE TEAM MANAGEMENT

DP INDUCTION

DP SIMULATOR

DP LIMITED

DP UNLIMITED

DP LOG BOOK

MANNED MODEL

13. HEALTH CERTIFICATE

FLAGE STATE

NUMBER

ISSUE DATE

EXPIRY DATE

ISSUED BY (AUTHORITY)

ISSUED AT

INTERNATIONAL

2029/2016

2016-05-31

2018-05-31

GDYNIA

LIBERIAN

NORWEGIAN

PANAMANIAN

SEA – SERVICE DETAILS

NAME:

SEBASTIAN LIPIEJKO

RANK:

4th ENGINEER

AVALIABILITY DATE:

1 SEPTEMBER 2016

COMPANY NAME

RANK

VESSEL NAME

SIGNED

ON

SIGNED OFF

VESSEL TYPE

G.R.T.

D.W.T.

ENGINE TYPE

BHP

KW

AKADEMIA MORSKA W GDYNI

ENG CADET

DAR MLODZIEZY

2013/09/04

2013/09/30

TALL SHIP

2255

SULZER

1500

VAN LAAR MARITIME

ENG CADET

EMANUEL

2014/04/01

2014/09/08

GUARD/SUPPORT

185

MITSUBISHI

1200

REFERENCE CONTACT DETAILS

COMPANY NAME

Van Laar Maritime

ADDRESS

Postbus 971970 AB IJmuiden (NL)

PHONE NO.

+31 (0) 255 - 518449

FAX/E-MAIL

acyie1@r.postjobfree.com

CONTACT PERSON

I declare that the information I have given is, to the best of my knowledge, true and complete. I also declare that the documents submitted are genuine and signed by the persons whose names appear on them.

2016/10/03

DATE

SIGNATURE

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