Application Form

Application Form

PLEASE COMPLETE AND RETURN TO

DEESIDE CREWING SERVICES LTD
4TH FLOOR
REGENT CENTRE
REGENT ROAD
ABERDEEN
AB11 5NS

Please attach a recent sized Passport photograph

Position Applied for

PERSONAL DETAILS

Surname	Christian name(s)	Date and place of birth
Marital Status	Nationality	Age and Sex of children (if any)

Passport No

Discharge Book

Expiry Date*

National Insurance No

Next of Kin

Name

Address

Relative

Postcode

Telephone

Medical History Have you ever suffered from any serious illness Yes / No Are you taking any medication at present Yes / No
Date last Eng1 carried out	Are there any Restrictions Yes / No
Name & Address of Doctor

TRAINING CHECK LIST STCW 95

STCW 95	Issue Date*	Expiry Date*	Limitations, Cert No`s
(PST) - Personal Survival Techniques
Fire Prevention & First Aid
Elementary First Aid
(PSSR) Personal Safety & Social Responsibility
Advanced Fire Fighting
Medical First Aid
Proficiency in Survival Craft & Rescue Boats (CPSC)
Fast Rescue Craft
Engine Room Watch Rating Certificate
Navigational Watch Rating Certificate
GMDSS - General Operator (GOC)
GMDSS - Restricted Operator (ROC)

OPITO CERTIFICATION DETAILS

Details	Issue Date*	Expiry Date*	Limitations, Cert No`s
ITSO - Initial Training Shipboard Operations
Fast Rescue Boatman
Fast Rescue Coxswain
Daughtercraft Coxswain
Command & Control

OTHER CERTIFICATION

Are you presently employed
Yes / No

Notice Period Required by Employer

Summary of Experience

PLEASE SUPPLY TWO REFEREREES(one must be your current employer)

Name

Position

Company Name

Address

Telephone

DETAILS OF SEA EXPERIENCE

* - date format is dd/mm/yyyy