Application Form and Doc No: Marine HR TKG - 51

Record of Personal Information and Past Valid From: 28/06/2005

Experience Version: 1
Author: John Williams

Please complete the attached form electronically (you can type directly in the fields provided).

Present rank: Rank applied for:       Date:      

Conventionalrecruit.sg@teekay.com     
Name in full (First, Middle, Last) Nationality Photo
           
Date of birth       Age       Married / Single / Divorced /
Widower      
Place of birth       Next of kin
Permanent / Contact address Name      
      Relationship      
Address      

(include international dialing code)

Telephone number Mobile number Fax number Email address
                       

Nearest airport       Colour of hair / eyes Height       Weight      
      /      

If accepted, date available for service: U.S. Visa Type Valid until
                       
Medical certificate expiry date: Other Visa Type Valid until
                       
Yellow fever vaccination expiry date: Other Visa Type Valid until
                       
Professional Qualifications
Licences Grade of Number Date issued Place Expiry Date
licence issued /
Revalidated
National                              
(please state)
     
Bahamian                              
     
Liberian                              
     
Panamanian                              
     
 Application Form and Doc No: Marine HR TKG - 51
Record of Personal Information and Past Valid From: 28/06/2005
Experience Version: 1
Author: John Williams

Seaman’s book Place & date Expiry date Passport Place & date Expiry date
number / issued nationality / issued
Nationality Number
                                   
Referees: 1)       2)      
Name, company
and contact
telephone number

Other professional qualifications / Certificates / Endorsements held

Course / Certificate Place held Date held Date of expiry
                       
                       
                       
                       
                       
                       
                       
                       
                       

Signature:
 Application Form and Doc No: Marine HR TKG - 51
Record of Personal Information and Past Experience Valid From: 28/06/2005
Version: 1
Author: John Williams

Previous Sea Experience

Vessel name Flag Deck: Trading area / Type of Company Rank Period Days / Months
Deadweight vessel name From – To
Engine: Type & BHP
Last                                                       /      
     
nd
2 Last                                                       /      
     
rd
3 Last                                                       /      
     
th
4 Last                                                       /      
     
th
5 Last                                                       /      
     
th
6 Last                                                       /      
     
th
7 Last                                                       /      
     
th
8 Last                                                       /      
     
th
9 Last                                                       /      
     
 Application Form and Doc No: Marine HR TKG - 51
Record of Personal Information and Past Experience Valid From: 28/06/2005
Version: 1
Author: John Williams

10th Last                                                       /      
     
th
11 Last                                                       /      
     
th
12 Last                                                       /      
     
th
13 Last                                                       /      
     
th
14 Last                                                       /      
     
th
15 Last                                                       /      
     
Other experiences (New buildings / Dry docks / Repair yards / Office secondments, etc.      
 Application Form and Doc No: Marine HR TKG - 51
Record of Personal Information and Past Valid From: 28/06/2005
Experience Version: 1
Author: John Williams

Marine Course Attended Date Attended Expiry (if any) Remarks

Merchant Navy Basic Fire Fighting (3                  
day)
Merchant Navy Advanced Fire Fighting                  
(4 day)
Merchant Navy Fire Team Leader /                  
Command & Control
Basic Sea Survival                  
Elementary First Aid (1 day)                  
Medical First Aid (4 day)                  
Proficiency in Medical Care Onboard                  
Ship
Certificate of Proficiency in Survival Craft                  
Specialised Tanker Training (Oil)                  
Specialised Tanker Training (Chemical)                  
Specialised Tanker Training (Liquid Gas)                  
Crude Oil Washing                  
Inert Gas Plant                  
Navigation, Radar & ARPA Sim Training                  
(Operational Level)
Navigation, Radar & ARPA Sim Training                  
(Management Level)
Electronic Chart Display & Information                  
Systems
Manned Model Shiphandling                  
Shiphandling Simulator Course                  
Engine room simulator Course                  
Bridge Team Management Course                  
Engine Team Management Course                  
Crew Resource Management Course                  
Crisis Management                  
Management of Major Emergencies                  
Personal Safety & Social Responsibilities                  
Dangerous Goods by Sea (IMDG)                  
Ship Safety Officer                  
Ship Security Officer                  
Efficient Deck Hand                  
Train the Trainer                  
Behavioural Safety Awareness                  
 Application Form and Doc No: Marine HR TKG - 51
Record of Personal Information and Past Valid From: 28/06/2005
Experience Version: 1
Author: John Williams

Safety Awareness / Accident Prevention                  

Abrasive Wheel Regulations                  
Welding                  
Crowd Management                  
Crisis Management & Human Behaviour                  
Passenger Safety, Cargo Safety & Hull                  
Integrity
Fast Rescue Craft (Boatman)                  
Fast Rescue Craft (Coxswain)                  
Draughtercraft Coxswain                  
Standby Vessel Advanced Medical Aid                  
Standby Vessel Command & Control                  
Standby Vessel - Initial Training for                  
Shipboard operations
Civil Aviation Authority Marine Operators                  
Certificate
Helicopter Underwater Escape Training                  
Helideck Assistant                  
Helicopter Landing Officer                  
Offshore Emergency Helideck Team                  
Member
Dynamic Positioning (Basic)                  
Dynamic Positioning (Advanced)                  
Any other Relevant Training: