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    Alpha Gas Application Form

    Uploaded by

    cristianvoinea13

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Alpha Gas Application Form

    Uploaded by

    cristianvoinea13
    9 views4 pages

    Original Title

    Alpha Gas Application Form(1)

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    9 views4 pages

    Alpha Gas Application Form

    Uploaded by

    cristianvoinea13

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    ALPHA GAS S.A.

    CHAPTER 6

    APPLICATION FORM FORM C 031A

    Date of Application:

    Rank Applied for: Recent Photograph

    Licence Holder:

    A. PERSONAL INFORMATION
    LAST NAME FIRST NAME

    OTHER NAMES NATIONALITY

    SEX M F BIRTH PLACE DATE OF BIRTH

    MARITAL STATUS COLOUR OF EYES HAIR COLOUR

    FATHER’S NAME MOTHER’S NAME

    VAT No. TAX AUTHORITY: MILITARY OBLIGATION FULFILLED: (YES/NO)

    NAT STATUS (active/retired) NATIONAL ID No: SOCIAL SECURITY No.:

    CRIMINAL RECORD : HAVE YOU EVER BEEN ARRESTED OR CONVICTED FOR A CRIME: YES NO

    HEIGHT (CM) WEIGHT (KG): NEAREST (INTL) AIRPORT:

    SHIRT SIZE BOILER SUIT SIZE (S,M,L,XL,XXL)

    WINTER JACKET SIZE SAFETY SHOES NO.

    COVID-19 VACCINATION 1ST DOSE TYPE / DATE 2ND DOSE TYPE / DATE BOOSTER DOSE TYPE /DATE

    B. RESIDENCE NEXT OF KIN

    STREET FULL NAME

    POST CODE RELATION

    CITY DATE OF BIRTH

    COUNTRY STREET, P.C.

    TEL. NO. CITY

    MOBILE COUNTRY

    E-MAIL TEL. NO.

    SKYPE ID MOBILE

    C. DETAILS OF CHILDREN
    NAME OF CHILD SEX DATE OF BIRTH
    M F
    M F

    Issue No. / Date: 01 / 01.06.2021 Revision No. / Date: 01 / 01.10.2022 Page 1 of 4


    ALPHA GAS S.A. CHAPTER 6

    APPLICATION FORM FORM C 031A

    D. FLAG ENDORSEMENTS
    Marshall Islands: ( YES / NO ) Malta: ( YES / NO )
    E. TRAVEL DOCUMENTS
    DOC./VISA TYPE DOC. NO. ISSUE DATE EXPIRY DATE ISSUE AUTHORITY COUNTRY
    PASSPORT
    SEAMAN BOOK
    US C1/D VISA
    F. ACADEMIC EDUCATION
    SCHOOL /ACADEMY NAME FROM TO
    SCHOOL /ACADEMY NAME FROM TO
    G. LICENCE INFORMATION
    LICENCE NAME NUMBER ISSUE DATE EXPIRY DATE ISSUE AUTHORITY COUNTRY

    H. LIST OF DOCUMENTS / TRAININGS ISSUE DATE EXPIRY DATE ISSUED BY (AUTHORITY)


    MEDICAL CARD

    YELLOW FEVER VACCINATION CERTIFICATE N/A

    BASIC SAFETY TRAINING

    PROFICIENCY IN SURVIVAL CRAFTS

    ADVANCE FIRE FIGHTING

    MEDICAL FIRST AID

    SHIP SECURITY OFFICER

    BASIC TRAINING FOR LIQUEFIED GAS TANKER CARGO OPERATIONS

    ADVANCED TRAINING FOR LIQUEFIED GAS TANKER CARGO OPERATIONS

    LNG CARGO HANDLING SIMULATOR

    STS SIMULATOR

    SHIP MANEUVERING (BAHIA BLANCA & ESCOBAR)

    SHIP HANDLING

    BRIDGE RESOURCE/TEAM MANAGEMENT (BRM/BTM)

    ENGINE RESOURCE/TEAM MANAGEMENT (ERM/ETM)

    HIGH VOLTAGE INSTALLATIONS

    SHIPBOARD SAFETY OFFICER

    MEDICAL CARE (DECK OFFICERS)

    SHIP SECURITY AWARENESS OR SHIP DESIGNATED SECURITY DUTIES

    PASSAGE PLANNING (DECK OFFICERS)

    ECDIS – GENERIC (DECK OFFICERS)

    ECDIS - TYPE SPECIFIC / JRC 7201-9201 or JRC 701-901 (DECK OFFICERS)

    MEDIA HANDLING ON CRISIS

    RISK ASSESSMENT

    HAZARDOUS ATMOSPHERE MONITORING

    INCIDENT INVESTIGATION AND ROOT CAUSE ANALYSIS

    Issue No. / Date: 01 / 01.06.2021 Revision No. / Date: 01 / 01.10.2022 Page 2 of 4


    ALPHA GAS S.A. CHAPTER 6

    APPLICATION FORM FORM C 031A

    I. SEAFARER’S SAILING RECORD (PLEASE START FROM THE LATEST SEA SERVICE)

    NAME: PRESENT RANK: DATE:


    SIGN OFF
    VESSEL NAME COMPANY NAME VESSEL TYPE (DESIGN) FLAG DWT. ENGINE TYPE BHP RANK SIGNED ON SIGNED OFF
    REASON

    Issue No. / Date: 01 / 01.06.2021 Revision No. / Date: 01 / 01.10.2022 Page 3 of 4


    ALPHA GAS S.A. CHAPTER 6

    APPLICATION FORM FORM C 031A

    J. LIST SEA SERVICE ON VESSELS WITH RE-LIQUEFACTION PLANT & TYPE

    K. SPECIAL OPERATIONS (gas freeing/gassing up, Cooling Down, Dry Dock, STS – GAS Tankers only)
    TOTAL NUMBER OF STS OPERATIONS: (GAS)

    L. AVAILABILITY
    AVAILABILITY DATE COMMENTS:
    M. REFERENCES
    COMPANY NAME
    ADDRESS
    PHONE NO.
    FAX/E-MAIL
    CONTACT PERSON
    N. ENGLISH PROFICIENCY
    FLUENT V. GOOD GOOD FAIR POOR

    CERTIFICATE OF COMPETENCY IN ENGLISH: ISSUE DATE:

    O. HOW / WHERE DID YOU HEAR FOR OUR COMPANY


    ACADEMY FRIEND / RELATIVE MARINE MAGAZINE / NEWSPAPER SOCIAL MEDIA OTHER (please specify):

    P. CONSENT TO USE PERSONAL INFORMATION


    In the process of the ordinary personnel administration and common services, I hereby submit to the Company my personal information as above, which is full and accurate, and I grant my
    consent to the Company to collect and use it with the purpose of personal identification, personnel administration, training programs registration, travel arrangements, etc. always within
    the governing law requirements.
    Signature: Date:

    Issue No. / Date: 01 / 01.06.2021 Revision No. / Date: 01 / 01.10.2022 Page 4 of 4

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