Office Information

Seafarer Application Form

*. PERSONAL INFORMATION

RANK Engine cadet, Wiper ALTERNATIVE RANK (IF ANY) LAST NAME Czerniewski FIRST NAME Dawid

OTHER NAMES Daniel NATIONALITY Poland

PESEL 940******** MOUSTACHE Yes No BEARD Yes No

SEX M F BIRTH PLACE Kołobrzeg/Poland DATE OF BIRTH 09.05.1994 MARITAL STATUS single COLOUR OF EYES blue COLOUR OF HAIR black MOTHER’S NAME Sylwia FATHER’S NAME Włodzimierz

HEIGHT (CM) 183 WEIGHT (KG) 79

INTERNATIONAL AIRPORT (NEAREST TO HOME TOWN): ZSS, GDN 2. ADDRESS (PERMANENT) ADDRESS (TEMP.) FROM/TO:

STREET Jedności Narodowej 90/24 STREET Jedności Narodowej 90/24 POST CODE 78-100 POST CODE 78-100

CITY Kołobrzeg CITY Kołobrzeg

COUNTRY Poland COUNTRY Poland

TEL. NO. TEL. NO.

MOBILE +48-796****** MOBILE +48-796******

E-MAIL *.*************@*****.*** E-MAIL

FAX FAX

3. NEXT OF KIN

FULL NAME Czerniewski Arkadiusz RELATION Brother

ADDRESS Jedności Narodowej 90/24 78-100 Kołobrzeg

CITY Kołobrzeg COUNTRY Poland

TEL. NO. MOBILE PHONE NO. 531506280 FAX NO.

4. BENEFICIARY INFORMATION

FULL NAME Czerniewski Arkadiusz RELATION Brother

ADDRESS Jedności Narodowej 90/24 78-100 Kołobrzeg

CITY Kołobrzeg COUNTRY Poland

TEL. NO. MOBILE PHONE NO. +48-531****** FAX NO.

5. DETAILS OF CHILDREN

NAME OF CHILD SEX DATE OF BIRTH

- M F

M F

M F

M F

6. TRAVEL DOCUMENTS

DOC./VISA TYPE DOC./VISA NO. ISS.DATE EXP. DATE ISS. BY (AUTHORITY) PLACE OF ISSUE PASSPORT EL 6049457 18.01.2017 18.01.2027 Gdynia Gdynia/Poland SEAMAN BOOK AA 0000411 10.02.2017 10.02.2027 Maritime Office in Gdynia Gdynia/Poland US C1/D VISA

OTHER VISAS

7. BANK ACCOUNT INFORMATION (OPTIONAL)

BANK NAME BRANCH

ADDRESS

CITY COUNTRY

ACCOUNT NO SWIFT/BIC CODE

8. EDUCATION

SCHOOL NAME The Gdynia Maritime School FROM 05.09.2016 TO SCHOOL NAME FROM TO

9. LICENCE AND COURSE INFORMATION

LICENCE NAME NUMBER

ISSUE

DATE

EXPIRY

DATE

ISSUED BY

(AUTHORITY)

ISSUED AT

Wiper GUM-13164-

142275-450/2017

indefinitely Maritime Office in

Gdynia

Gdynia/Poland

COURSE NAME NUMBER

ISSUE

DATE

EXPIRY

DATE

ISSUED BY

(AUTHORITY)

ISSUED AT

PERSONAL SURVIVAL

TECHINQUES

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

55867/2016

20.09.2016 15.09.2021 Maritime Office in Gdynia Gdynia/Poland BASIC FIRE FIGHTING GUM-542*-******-

55867/2016

20.09.2016 15.09.2021 Maritime Office in Gdynia Gdynia/Poland ADV. FIRE FIGHTING

ELEMENTARY FIRST AID GUM-542*-******-

55867/2016

20.09.2016 15.09.2021 Maritime Office in Gdynia Gdynia/Poland MEDICAL FIRST AID

MEDICAL CARE

PERS. SAFETY & SOC. RESP. GUM-542*-******-

55867/2016

20.09.2016 15.09.2021 Maritime Office in Gdynia Gdynia/Poland PROF. IN SURVIVAL CRAFT

FAST RESCUE BOATS

CERTIFATE OF PROFICIENCY IN

SECURITY-AWARENESS.

In progress

CERTIFICATE OF PROFICIENCY

FOR SEAFARERS WITH

DESIGNATED SECURITY DUTIES.

PERMISSION ON LPG TANK.

GMDSS

RADAR OBSERVER

ARPA

HAZMAT in progress

HEALTH CERTIFICATE: 64/2016 20.12.2016 20.12.2018 Medica Assistance S.A. Gdynia/Poland YELLOW FEVER

DRUG & ALCO TEST

PILOT EXEMPTION CERTIFICATE:

OTHER:

10. ENGLISH PROFFICIENCY

FLUENT V. GOOD GOOD FAIR POOR

18.02.2017 Czerniewski

Date Singnature

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