CREW DATA SHEET
WAPPEN-REEDEREI
PERSONAL DATA
Date:
Name:
Instructions:
Required
Initially Not Required
For CPT, C/M, 2/M, C/E + 2/E Only
PERSONAL DETAILS
Position:
Alternative:
Vessel:
Flag:
Surname:
First Name:
Middle Name:
Date of Birth:
Place of Birth:
Nationality:
Sex:
Civil Status:
No. of Children:
Photo:
* (only .jpg/.gif/.png)
* click here, search for your photo-file, click on it and enter.
ADDRESS
Street:
Tel.:
City:
Mobile:
Country:
Fax:
Airport:
E-Mail:
NEXT OF KIN
Name:
* Tel.:
Relation:
* Fax:
Street:
City/Country:
* If same as above, please insert "As above"
NATIONAL IDENTITY DOCUMENTS / VISA
Passport No:
Issued:
Expiry:
SB-Book No:
Issued:
Expiry:
US-VISA:
Issued:
Expiry:
Other Visa:
Issued:
Expiry:
LANGUAGES
Level of English:
Test passed:
Date:
Mother Language:
Remarks:
Other Language:
MEDICAL EXAMINATION (HEALTH CERTIFICATES)
Clinic:
Issued:
Expiry:
VACCINATIONS (VALID FOR DURATION OF CONTRACT)
Cholera:
Yellow Fever:
Typhoid:
Tetanus:
Hepatitis B:
Shot:
1.
2.
3.
DRUG AND ALCOHOL TEST
Clinic:
Issued:
NEG
POS
Result:
If test results are positive, pls state reason (e.g. prescribed medication etc.):
CREW DATA SHEET
WAPPEN-REEDEREI
EXPERIENCE
Date:
Name:
TRAINING COURSES
(All Training courses / Seminars / Upgrading courses other than STCW/Flag state requirements)
Training Course / Seminar
Location
Duration
Date
GRADUATED FROM:
FORM OF EDUCATION:
WORKING CLOTHES:
Overall size / Safety shoes size
Height
Eyes
SEA SERVICE
(Complete sea service record for at least last 10 employments)
Name of vessel
Flag
Type
Engine
Company
Rank
S/on
Months/Days
Year built
GRT
kW
Crew Agent
S/off
CREW DATA SHEET
Date:
WAPPEN-REEDEREI
QUALIFICATION STCW-95 and WAPPEN-REEDEREI
Name:
1. BASIC SAFETY TRAINING STCW (A-VI/1) (Revalidation is not required)
No.
Date of issue
1.1
When holding a
certificate incl.
below mentioned
No.
Date of issue
No.
Date of issue
1.2
Personal
survival
1.4
Fire
fighting
No.
Date of issue
No.
Date of issue
1.3
Elementary
first aid
1.5
Personal
safety
2. STCW - ADDITIONAL TRAINING (A-VI/2~4) (Revalidation is not required)
No.
Date of issue
No.
Date of issue
2.1
Rescue
boats
2.4
Medical
first aid
No.
Date of issue
No.
Date of issue
2.2
Fast rescue
boats
2.5
Medical
care
No.
Date of issue
2.3
Advanced
first fighting
3. CERTIFICATE OF COMPETENCY (A II/1-4, A III/1-4) Officers and watchkeeping ratings
No.
Date of issue
Date of expiry
3.1
Capacity
4. OTHER CERTIFICATES
No.
Date of issue
Date of expiry
Type (GOC or ROC)
4.1
GMDSS
Score
Date of test
Date of issue
4.2
Marlins Test
4.5
AVECS TITAN
training
No.
Date of issue
Date of issue
4.3
ECDIS training
4.6
IMO course 1.22
No.
Date of issue
4.4
BTM
5. SPECIAL REQUIREMENTS TANKER (A V/1)
No.
Date of issue
No.
Date of issue
5.0
Shore based
fire fighting
5.3
Oil tanker
advanced
No.
Date of issue
No.
Date of issue
5.1
Tanker
famliliarization
5.4
Chem tanker
advanced
No.
Date of issue
5.5
Gas tanker
advanced
No.
Date of issue
No.
Date of issue
5.2
COW
5.6
Inert
Gas
6. SPECIAL REQUIRMENTS DRY CARGO VESSELS CARRYING DANGEROUS CARGO
No.
Date of issue
No.
Date of issue
6.1
HAZMAT
6.2
HAZMAT
employee
7. ANY OTHER ADDITIONAL QUALIFICATIONS