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
MOBILE
*****************@*****.***
FAX
FAX
3. NEXT OF KIN
FULL NAME
ZBGINIEW LIPIEJKO
RELATIONSHIP
FATHER
ADDRESS
PARTYZANTOW 5A
CITY
BARTOSZYCE
COUNTRY
POLAND
TEL. NO.
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
****@***************.***
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