INTERNATIONAL MARITIME AGENCY IN ODESSA

 (IMAO)

17, Kanatnaya str., Odessa, 65014, Ukraine
tel/fax: (+38 048) 777-60-99 tel: (+38 048) 777-61-10
e-mail: imao@odessa.net http://www.imao.odessa.net/

APPLICATION FORM FOR SEA STAFF

Position applied for JPG Photo 34X45mm
Surname:
Name:

Middle Name:
Age: (yrs)
Date of birth:
Place of birth:
Nationality:
Passport No.:

Date issued:
 
Place issued:

Passport valid till:
Seaman Book/C.D.C. No.:
Issued by Govt.of
Date of issue:
 
Valid till:

Port of issue:
Certificate of Competency as:
Issued at port of:

Issued by Govt. of
Certificate No.:
 
Date of issue:
Endorsement:
   
Others licenses:
   
Present address:
Telephone number:
   
Next of kin name and address:
Mobilephone number:

Relationship:
   
Telephone number:
Marital status:
Married
Single

No. of children:
Children: Names and dates of birth
   
Academic Background
Names of Schools/Colleges attended Country & city From To Qualifications achieved
Pre-sea background all applicants
Names of training establishments Number Country & city Date issued
STCW 78/95
MEDICAL AID/CARE
HAZARDOUS CARGOES
RADAR OBSERVER
ARPA
ADVANCED FIRE FIGHTING
GMDSS + ENDORSEMENT
SHIP SECURITY
ISM -CODE (SHIP SAFETY OFF)