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Delta Marine Personnel Services Ltd.

Delta Marine Personnel Services Lockside Marina Navigation Road Chelmsford CM2 6HF E - M a i l : Crewdept@deltamarine.co.uk

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Please complete this form in black ink or type 1 CONTACT DETAILS (Enter Details) RANK DEPARTMENT Title First Names Surname Postal Address Deck/Engineer Country of Residence Place of Birth Date of Birth Nationality Tel No 1 Tel No 2 Fax No E Mail Nearest Station/Airport 2 TYPE OF EMPLOYMENT SOUGHT (Enter Details) Seeking Temporary Employment (Tick Box) Max Tour of Duty Trading Area 3 AVAILABILITY (Enter Details) Date Available From 4 BANK DETAILS (Enter Details) Bank Name Bank Address Account Holders Name Bank Sort Code Bank Account No National Insurance No 5 NEXT OF KIN DETAILS (Enter Details) NOK Name NOK Tel No NOK Relationship 6 CERTIFICATE OF COMPETENCY (latest only) (Enter Details) (Please include copies for our records) DETAILS ISSUE DATE EXPIRY DATE COUNTRY OF ISSUE LIMITATIONS, CERTIFICATE No's etc NOK Address As above Date Available To Unknown Seeking Permanent Employment (Tick Box) Position Sought Ship Types

7 ENDORSEMENTS (Tick Boxes which apply) DCE Chemicals DCE Gas DCE Petroleum

8 CERTIFICATE CHECK LIST (Enter Details) (Please include copies for our records) DETAILS Discharge Book / Seamans Book Passport ENG1 / Medical Certificate US Visa UK Work Permit (if Applicable) ISSUE DATE EXPIRY DATE LIMITATIONS, CERTIFICATE No's etc

9 SHIP EXPERIENCE (Tick Boxes which apply) CARGO Bulk Car Carrier Container Ship G Cargo - Coastal G Cargo - Deep Sea Livestock Carrier Reefer OFFSHORE AHTS Buoy Tender Cable Layer Drill / Rig / Semi-sub DSV - Dive Support Standby Supply Survey Tug 10 MAIN ENGINE EXPERIENCE (Engineers only) (Tick Boxes which apply) Allen British Polar Bukh Burmeister & Wain Daihatsu Diesel Electric Deutz Dorman Doxford General Motors Gotaverken Hedamora Lister MaK MAN Mirrlees Blackstone Mitsubishi Mitsui Paxman Petter Pielstick Rolls Royce Ruston Scania Steam Turbine Stork Stork Werspoor Sulzer Wartsila Yanmar PASSENGER Cruise Ship Fast Ferry (inc CAT) Freight Ro-Ro Passenger Ro-Ro TANKERS Chemical FPSO LNG LPG Product Coastal Product Deepsea VLCC / ULCC GENERAL Dredger Fishing Vessel Hopper Barge Research Vessel Royal Fleet Aux (RFA) Royal Navy Yacht

11 MAIN ENGINE SPEED EXPERIENCE (Engineers only) (Tick Boxes which apply) Slow Speed Medium Speed High Speed

12 SUPPLEMENTARY CERTIFICATES CHECK LIST (Enter Details) (Please include copies for our records) STCW 95 SUPPLEMENTARY CERTIFICATES Personal Survival Techniques (PST) Fire Prevention & Fire Fighting Elementary First Aid Personal Safety & Social Responsibility (PSSR) Advanced Fire Fighting Medical Care Medical First Aid Proficiency in Survival Craft & Rescue Boats (PSC&RB) Fast Rescue Craft Engineroom Watch Rating Certificate (Ratings) Navigational Watch Rating Certificate (Ratings) STCW 78 SUPPLEMENTARY CERTIFICATES Basic Sea Survival Ship Captain's Medical First Aid at Sea Stage II Fire Fighting (4 day) Stage I Fire Fighting (2 day) Navigation, Radar & ARPA Simulator Navigation Control (NCC) Electronic Navigational Systems (ENS) Proficiency in Survival Craft (CPSC) OTHER SUPPLEMENTARY CERTIFICATES Offshore Survival (OPITO) GMDSS (GOC) GMDSS (ROC) Other Other ISSUE DATE EXPIRY DATE LIMITATIONS, CERTIFICATE Nos etc ISSUE DATE EXPIRY DATE LIMITATIONS, CERTIFICATE Nos etc ISSUE DATE EXPIRY DATE LIMITATIONS, CERTIFICATE Nos etc

13 SEA EXPERIENCE (Previous Sea Experience Earliest Date First) Name: Company Rank Ship Name Ship Type GT Engine Make/Power Slow/Med/High Date From Date To

14 PLEASE USE THIS BOX TO INCLUDE ANY ADDITIONAL INFORMATION RELEVANT TO YOUR APPLICATION

15 REFEREES (Enter Details) REFERENCE 1 Can we take up this reference NOW / LATER? Title First Names Surname Address REFERENCE 2 Can we take up this reference NOW / LATER? Title First Names Surname Address

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I confirm that the details given are to the best of my knowledge accurate and true, that I am in legal possession of the above qualifications and certificates. I also confirm that I have no unspent criminal convictions Signature: Date: