App. Form
dHLE MANNING AGENCY S.R.L 155 Mamaia Blvd., 900575 Constanta
ROMANIA, Tel : + 40241 638111, 638112, +40341710110 , Fax : + 40241
638133; Email: [email protected] application
formdate: Position applied forPICTURE
Date of availability
Surname
Name
Date / place of birth
Marital status
Other Foreign languages
Contact informationHome addressPhone
Mobile
Email
Nearest Airport
Identity / travel documentsDocumentSerial/NumberDate of
IssueDate of Expiry
Passport
US Visa /Type
Other Visa
Seamans Book
Next of kin Details
Relationship (i.e. Wife, Father etc.)
Name and Surname
NOK address (if same, write SAME)
nok Contact Number
Age of Children (if applicable)
PRE-SEA EDUCATION
Name of school or academyDepartmentFromTo
Documents
Name of documentNumberPlace of issueDate of issueDate of
expiry
Certificate of Competency
Endorsement
Basic Safety Training
Personal Survival Techniques
Pers. Safety & Social Responsibilities
Medical First Aid
Fire Prevention and Fire Fighting
Transp. and handling of Dang. Cargoes
Prevention of Pollution Marpol
Prof. Survival Craft / Rescue Boats
A.R.P.A.
ECDIS
Advanced fire-fighting
Medical Care
Bridge/Engine Team Management
SSO ( STCW A-VI/5 )
Security awareness (STCW A-VI/6)
GMDSS GOC
National Medical Examinations
Vaccination against Yellow Fever
SEA SERVICE DETAILSRankCrewing AgencyName of
vesselFlagTypeGRTEngine type/ KWDate FromDate To
SHORE EMPLOYMENT DETAILS
EmployerRankJob detailsDate From Date To
REFERENCES from last 2 employers
EmployerPerson of Contact Name of vessel/ShippyardTelEmail
Cunoscand prevederile art. 292 din Codul penal cu privire la
falsul in declaratii, declar pe propria raspundere ca datele si
informatiile prezentate corespund realitatii si ca nu sufar de vreo
boala cronica sau de vreo disabilitate fizica sau psihica
permanenta
Semnatura aplicantului: SC Dohle Manning Agency SRL este
inscrisa in Registrul de Evidenta a Prelucrarilor de date cu
caracter personal sub numarul 19966.Datele cu caracter personal
furnizate de dvs in acest document sunt utilizate n scopul
prezentarii candidaturii dvs pentru o posibila angajare. Datele vor
fi dezvluite numai clientilor nostrii, posibili angajatori. Pe
viitor, aceste date ne permit s v inem la curent cu activitatea
noastr. n cazul n care nu dorii aceasta, nu va vom putea lua in
considerare aplicatia si nu va vom inregistra in baza de date.
Conform Legii nr. 677/2001, beneficiai de dreptul de acces, de
intervenie asupra datelor, dreptul de a nu fi supus unei decizii
individuale. Avei dreptul s v opunei prelucrrii datelor personale
care v privesc i s solicitai tergerea din baza noastra de date.
Pentru exercitarea acestor drepturi, v putei adresa cu o cerere
scris, datat i semnat la sediul nostru. De asemenea, v este
recunoscut dreptul de a v adresa justiiei. Datele dvs vor fi
transferate n statele Uniunii Europene, Marea Britanie, Elvetia,
Singapore, Philippine, India si Ucraina n vederea unei posibile
angajari. Dac unele din date sunt incorecte, v rugm s ne informai
ct mai curnd posibil.
F 03-03-01
Copyright Dhle Manning Agency Romania
