1. Maritime Experience and Certificates
Mr.Dusan Dijan
Croatia-EU
Spincici 61, Kastav
Tel: +385-51-274925
Cell Ph: +385-98-257521
Fax: +385-51-718004
E-mail: dusan.dijan@ri.t-com.hr
G-mail: dusan.dijan@gmail.com
Application Form Deck & Engineering Officers
Section 1 Position
Position Applied for Electrical engineer- Electrician (Electrical officer)
Lowest Position Acceptable Negotiate about- flexible
Date of Availability 01- 03- 2016
Section 2 Personal Details
Family name / Surname Dijan
First Name / Given Name Dusan
Date & Place of Birth Date - 16.09.1960. Place- Rijeka
Nationality Croatian
Permanent Address Spincici 61, Kastav 51215
Present Address Same above
PPE information SAFETY SHOES SIZE 10 (44) COVERALL SIZE Xl (46)
Blood Group O RH+
Physical Information 180 cm 99 Kg
Present Contact Number +385-51-274025
Mobile Number +385-98-865995
SKYPE ADDRESS ddijan1
Email Address dusan.dijan@ri.t-com.hr
Nearest Airport (and Distance) Trieste ( Italy cc 60 Km), Zagreb ( Croatia cc.180 Km)
Section 3 Passport and VISA details
Country of Issue Croatia USA Visa - Type B1/OCS
Date Issued 02.11.2011. USA VISA Expires
Place Issued Rijeka USA Visa - Type C1/D
Passport Number 135492793 USA VISA Expires
Passport –Expires 02.11.2021. Other Country Visa
Secondary passport or Dual nationality Visa Expiry
Section 4 ( hi-light as required ) Seaman book / Discharge book / Seaman Record Book / CDC
Issuing Country & Place Croatia, Rijeka Date Issued 02.11.2011.
Number 15492793 Expiry Date (if any) 02.11.2021.
Section 5 Next of Kin – this is important information we require- Don’t ignore it
Full Name / Relationship Liljana Dijan / Wife
Any dependents / Children (incl age ) Non / Non
Address Some above
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APRIL 2015 Rev - 07

2. Contact Numbers ++385-98-865995
Page 1 of 7
Section 6 STCW95 Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)
Class /
Grade/Capacity
Issuing
Country
Certificate No. Date Issued Expiry Details of Limitations
Electronic
Automation
Technician
Croatia
(ex
Yugoslavia)
D-8/ 1977
86-1978/79
02-4/67-79
25.june
1979.
Unlimited
Ship’s
Electrician
Croatia 400156492 14.08.2012. Unlimitd
Liebherr cargo crane Austria Operation/ main
ALSO ENTER ABOVE DETAILS OF ANY OTHER FLAG STATE CERTIFICATES HELD
Section 7 STCW95 Dangerous Cargo Endorsements
Petroleum…………….
Liquefied Gas……….
Liquid Chemicals…….
Certificate No. Date Issued Expires Details of Limitations/ Grade
Section 8 STCW95 related Courses Attended and Certificates Obtained
Name of Course / Certificate STCW Code Place Issue Date Cert No Expiry Date
Basic Safety Training A-VI/1 Rijeka 26.03.2012. 400152114 31.12.2016
Basic Sea Survival / Personal Survival
Techniques
A- VI/1-1
Fire Prevention & Fire Fighting A-VI/1-2
Elementary First Aid A-VI/1-3
Personal Safety & Social Responsibility A-VI/ 1-4
Proficiency in Survival Craft & Rescue
Boats
A-VI/ 2-1 Rijeka 26.03.2012. 400152112 31.12.2016
Proficiency in RESCUE CRAFTS
Proficiency in FAST RESCUE BOATS A-VI/ 2
Advanced Fire Fighting A-VI/ 3 Rijeka 16.03.2012. 400152113 26.02.2017
Medical & First Aid A-VI/ 4-1 Rijeka 19.03.2012. 400152057 19.03.2017
Medical Care
( Ship Captains Medical Course )
A-VI/4-2
Radar & ARPA Simulator Trg-
Management level
A-II/ 1-2
Electronic chart Display and
Information System course
(ECDIS)
A-II / 1
GMDSS + ENDORSEMENT A-IV/ 2
SAFETY OFFICERS COURSE (SO)
Ship Security Officers Course (SSO)
Issued under STCW95
A-VI/ 5
Proficiency in Security Awareness A-VI/6 Rijeka 16.04.2014. 400212958 Unlimited
Proficiency in Designated Security
Duties
A-VI
Medical Certificate / HEALTH
Certificate
MLC Rijeka 20.09.2015.
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3. Compliant
Drug and Alcohol test certificate Rijeka 14.01.2016.
YELLOW FEVER On demand
Bridge Team Management A-II/2
Bridge Resources Management B-VIII/2
ISM Code A.1441 (18)
Engine Room Resources Management
( Operational Level / Management level )
A-III/1, A-III/2,
A-III/3,A-VIII/2
HELM (leadership and management skills ) A-II/2, A-III/2
TANKERS FAMILIARISATION A-V/1
Advanced Tanker Operations (Chem.) A-V/1-2
Advanced Tanker Operations (Oil) A-V/1
Advanced Tanker Operations (LPG) A-V/1
REFRESHER & UPDATING I/II & III/2
Page 2 of 7
Section 9 OFFSHORE INDUSTRY COURSES
Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned
Name of Course / Certificate APPROVALS Place Issue Date Cert No Expiry
BOSIET / FOET
HUET
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
Re-Breather training
Initial Standby vessel crews training ( ITSO )
CAA (Civil Aviation Authorities – Helicopter)
Advanced Medical Aider ( AMA )
HLO
HLA
MARLIN’s English Test Score: %
IELTS-English TEST http://www.ielts.org/test_centre_search/search_results.aspx SCORE
PMS maintenance system – Confirm that you are Familiar with its use ( YES / NO ) YES
DEEP WATER ANCHOR HANDLING EXPERIENCE ENTER DEPTH IN METERS ???????
DP Maintenance Courses
DP Maintenance Courses
HIGH VOLTAGE COURSE
Dynamic Positioning Induction Course
Dynamic Positioning Simulator Course
Dynamic Positioning Operators
CERTIFICATE
Full or
Limited
Dynamic Positioning Log book Details
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4. Section 10 Hours done with various DP system
SYSTEM DETAILS Approx Hours as SDPO / Approx Days
in case of Senior ETO / Senior Engineer
Approx Hours as DPO / Approx Days
in case of Junior ETO / Junior Engineer
APPROXIMATE Total DP Hours in Various Operations
SAT DIVING CABLE LAYING
AIR DIVING SURVEY
ROV PIPE LAYING
WELL STIMULATION / INTERVENTION /
ACTIVATION
DRILL SHIP / SEMI SUB
AHTS PSV
FPSO SHUTTLE TANKER
CONSTRUCTION ROCK DUMPING / MATTRESSING
CORING TRENCHING
HEAVY LIFT Experienced ACCOMMODATION / GANGWAY
Page 3 of 7
Section 11 Medical History
YES NO
1. Have you ever signed off a ship due medical reason and been hospitalised? X
2. Have you ever been signed off the vessel and repatriated due illness? X
3. Have you undergone any medical operations in past? X
4. Have you consulted a doctor during the past 12 months for an illness / Accident X
5. Do you have any health or disability problem now?? X
6. Any Past Medical Condition – Which May Affect Your Work :- (If Yes Than Please Specify Below)
7. Do you feel healthy and fit to perform the duties of your designated
position/occupation?
X
8. Are you allergic to any medications?- If Yes, then please identify below NO
Allergic to Medications :
9. Are you taking any non-prescription or prescription medications at present? NO
If yes, please list the medications taken, and the purpose(s) and dosage(s):
PRESCRIPTION MEDICATION:
NON-PRESCRIPTION MEDICATION:
WPIF – M/01 20TH
APRIL 2015 Rev - 07

5. If answer to any of above is YES then give further details below or on a separate sheet
NOTE : All our clients have STRICT Alcohol and Drug Policy,
Which means ZERO TOLERENCE for alcohol and drugs
Section 12 General
Yes No
Have you ever been involved in a maritime accident, ie grounding, fire, Explosion, Collision.etc X
Have you ever been the subject of a court of enquiry or involved in a maritime accident X
Have you ever had a professional licence suspended or revoked X
Have you ever been convicted of any criminal offence? X
Have you ever been dismissed due any reason X
If yes to any of above then please full details below or on separate sheet of paper
Section 13 PROVIDE DETAILS OF YOUR LAST TWO EMPLOYERS, IN
ORDER TO OBTAIN CONFIRMATION ON YOUR SEA SERVICES
Name of company T.ransocean Maritime Ag
Name Person to be contacted Mr. Nenad Dujmovic
Address Monaco, Rue Grimaldi 57
Tel No Fax
Email
Name of company RHL Reedeei Hhamburger Lloyd
Name Person to be contacted
Address Zirkusweg2, 20359 Hamburg Germany
Tel No Fax
EMAIL fleet@hamburger-lloyd.de
Section 14 Any other information, you wish to add in support of your application
Planning additional education in UK related with my occupation. Future Company support in education
and additional Course’s need for job are acceptable and thankful for offer. From my side guarantee
my max output in job same as loyalty to my employer.
Section 15 Declaration – MUST BE SIGNED BY ALL APPLICANTS
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
And confirm that All my certificates / Licences are Authentic / SEASERVICE RECORD is ACCURATE / And I confirm
accepting Companies DRUG & ALCOHOL Policy
Signed ………………………… Date…………………..
Page 4 of 7
Note: On next page down is some of my Sea Service records.
Please ask for any additional information You need.
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APRIL 2015 Rev - 07

6. Section 16 Record of Sea Service (All Dates to be entered as
dd/mm/yy)
Please give full record of sea service STARTING FROM LAST VESSEL FIRST
VESSEL COMPANY Type of Vessel
And Type of
operation in case
of DP vessels
DWT or GRT
(please delete as reqd)
Type of Engines
Or DP System
BHP RANK Sign on
DATE
Sign off
DATE
dd / mm / yy dd / mm / yy
M/V Atlas TMA, MONACO Handy self loading 38 500 KW 11.000
ELECTRICAL
ENGINEER
26.06.99. 02.11.99.
M/V Achilles TMA, MONACO Handy self loading 37 600 KW 10.500
ELECTRICAL
ENGINEER
01.02.00.
18.07.00.
M/V Azur TMA, MONACO Handy self loading 37 000 KW 12.000
ELECTRICAL
ENGINEER
15.11.00. 17.05.01.
M/V Avalon TMA, MONACO Bulk carrier 75 000 KW 10.000
ELECTRICAL
ENGINEER
29.01.02. 28.06.02.
M/V Antwerpia TMA, MONACO Bulk carrier 75 000 KW 11.500
ELECTRICAL
ENGINEER 31.01.03 01.08.03.
M/V Ascanius TMA, MONACO Bulk carrier 75 000 HP 12.670
ELECTRICAL
ENGINEER
20.02.04. 02.08.04.
M/V Avalon
TMA, MONACO
Bulk carrier
38.000
KW10.000
ELECTRICAL
ENGINEER
23.04.05. 28.09.05
M/V Apollo
TMA, MONACO
Bulk carrier
75.000
HP 12.670
ELECTRICAL
ENGINEER
31.01.06. 16.06.06
M/V Amazon
TMA, MONACO
Bulk carrier 165.000
HP 16.900
ELECTRICAL
ENGINEER
17.04.07. 20.07.07
M/V FLOOTBEK RHL,Hamburg
CONTAINER
FEEDER HP 12640
ELECTRICAL
ENGINEER
16.08.12 11.12.12.
Previous Sea Service since 1983 Y
Automation
Typ
AEG- Simens Terasaki NOR- Control Etc.
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7. Shore job Shipyard Dry dock Different Aut. Green energy Power energy Etc.
Type of Engines :: for engineers only, DPOs to Mark DP System BHP : for Engineers and AHTS / TUG Masters & Officers Page 5 + 6 of
7
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APRIL 2015 Rev - 07

8. ADDITIONAL INFORMATION SHEET
VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)
1. Heavy lift –self loading gear (experienced )
2. PLC- CLC- Construction Vessel, Dredger
3. Container Feeder (experienced )
4. Bulk carrier (all size’s experienced)
5. All Type of Vessel, ready for additional Courses and education future need.
MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below)
Please Quote –Consolidated MINIMUM MONTHLY SALARY ( no leave pay ) payable for
time onboard only or Working DAY RATE EXPECTATION ( no leave pay)
( please quote below in US$ -preferred or Euro or GBP£ )
All negotiable ( I’ am professional and flexible person with target for specialized Vessels as my
priority interest were I’ can use my skills and experience for the best of all).
Languages Spoken / Written / Understood (1-poor 5-Fluent)
Spoken Written Understood
ENGLISH Fluent Fluent Fluent
DRUG & ALCOHOL POLICY
ALL Our Clients have very strict NO DRUG and ALCOHOL POLICY, Which is required to be
complied with at all times, which means “””ZERO TOLERENCE on ALCOHOL & DRUG”””
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight
or commence your travel to join vessel, and Must remain so Until you have completed full contract
and returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL
EXPENCES incurred which will include all your travel and recruiting costs, And your relief’s
Travel and recruiting costs, And Any other costs whatsoever incurred due to your NON-
COMPLIANCE will be deducted from your salary, Which will include but not limited to “damage to
vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly
connected with your NON-COMPLIANCE
Sign & CONFIRM ACCEPTANCE OF ABOVE POLICY………………………………………
FOLLOWING DOCUMENTS COPIES MUST BE SENT TO US- send to us In separate Email
All Certificates / Courses Listed in this form + Licence or Certificate of competency, Any tanker
endorsements, GMDSS showing expiry date in case of Deck Officers, Medical Fitness / Examination
Certificate, Passport Main page, Seaman book or Discharge book Main pages, In case of DPO – DPO Cert,
DP LOG Pages
FOLLOWING ADDITIONAL DOCUMENTS will ALSO BE REQUIRED – Send to us in separate email
All short courses certificates ( STCW95 ), SSO certificate, Last 3-5 years ships entries in Discharge book or
Seaman book, Certificate of Equivalent Competency from other flag states
PAGE 7 of 7
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