1. SEAFARER'S APPLICATION FORM - Page 1 of 4 - PERSONAL DATA
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT - PAGINA 1 DIN 4 - DATE PERSONALE)
PERSONAL INFORMATION( DATEPERSONALE) A/B,Bosun
FamilyName(Nume) GUGEAMAN First Name(s) (Prenume) DIONISIE DORU
Birth Date (DataNasterii) 25/11/1969 Birth Place (Locul nasterii) M.KOGALNICEANU
Nationality(Nationalitate) ROMANIAN Weight (kg) (Greutate in Kg) 85
Marital Status (Stareacivila) MARRIED Height (cm) (Inaltime) 180
No. of Children (Nr copii) 1
Nearest Airport (Cel mai apropiat aeroportinternational) BUCHAREST
ADDRESS (include telephonecountry & areacodes,advisealsosecondary or contactaddresses ifany)
ADRESA (incluzand nr telefon, tara si cod zona, a doua adresa sau adresa de contact , dacaeste cazul )
Street& Nr (Strada si Numar) Str.TRAIAN 66 Email Address (AdresaEmail) doru_gugeaman@yahoo.com
Location (Locatie) Bl K2,Sc A, Ap 26 Mobile Phone (Tel mobil) 0040 721183503
City (Oras) CONSTANTA Residence Phone (Tel fix) -
State, Country (Judet) ROMANIA Fax (Fax) -
Postal (ZIP)Code (Cod) 900716 P.O. Box (ifany)(CP)
NEXT OFKIN INFORMATION (person tocontactin caseof emergency & insurance beneficiary)
RUDA CEA MAI APROPIATA/ IMPUTERNICITA ( personade contact in caz de urgentasi beneficiarul asigurarilor)
FamilyName(Nume) GUGEAMAN First Name(s) (Prenume) FLORICA
Nationality(Nationalitate) ROMANIAN Relationship (Grad de rudenie) MOTHER
Street& Nr. (Str.si Nr.) Str.MIRCEA CEL BATRIN
152
Email Address (Adresaemail ) -
Location (Locatie) MD 12B,Sc C,Ap 71. Mobile Phone (Tel mobil) 0040 733749476
City (Oras) CONSTANTA Residence Phone (Tel fix) 0040 241580670
State, Country (Judet) ROMANIA Fax (Fax)
Postal (ZIP)Code (Cod) 900653 P.O. Box (ifany)(C.P)
REMARKS (REMARCI)
Requested Rank (Functie) A/B, AvailabilityDate (Disponibil din) 2016
Prefer. Vessel Type (Tip de nava
preferat)
ANY Minimum Salary(Salariu minim) --
SUMMARY OFQALIFICATION ANDEXPERIENCE ( CALIFICARESI EXPERINTA)
Years with operator (Ani cu actualuloperator) 10 years
Years in rank (Ani in functiaactuala) 7,6 years(91,2months)
Years on AHTS/TUG SUPLLY ( Ani pe nave tip remorcher) 36,5 months
Years on chemical-/oil tankers (Ani pe nave tip tanc ch/oil) 23,2 months,
Years on LPGtankers (Ani pe nave tip tanc LPG) 6,8 months
Years on tankers (all types)(Ani pe nave tip tanc – in general) 30,0 months
English Language Skills (Limbaengleza/ Nivel cunoastere) Spoken:/good/- Written:: /good
(Vorbit: fluent /bine /mediu - Scris : fluent/ bine /mediu )
OtherForeign Languages (Alte limbi straine) ITALIAN
Professional School / Academy - Name & Period (From - To)
(Scoala/ Nume/ Perioada)
Graduated economic highschool “Grup Scolar Industrial Tomis”
Constantaand Vocation School Graduation –Naval Constructions
Locksmith and Hempel Company
-Maritime School in Constanta
Foreign Crew Experience (specifynationalities)
Experinta cu echipaje straine (specificati nationalitatile)
Italian, Poland, Filipino,Lituanian,U.K.
OtherSkills (Alte calitati profesionale) Licence for ForkLift , DriverLicence ,,B’’
Further Remarks (Alte remarci)
2. I herebyaffirm that all the information provided by me in this application is true and correct tothe bestof my knowledge.
Prin prezenta confirm ca toate informatiile date de catre minein aceast formular de applicare sunt adevarate si corecte
Date:
Data :..2016
Signature:
Semnatura DoruDionisie Gugeaman
SEAFARER'S APPLICATION FORM - Page 2 of 4 - LIST OF DOCUMENTS
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT - PAGINA 2 DIN 4 – LISTA
DOCUMENTELOR)
Please notethat due to legal requirements boardingis only possible oncewe are in possessionof photocopies ofall listed documents andcertificates -
in urgent cases youmay thereforehave tosendthemby courier,fax oremail (.jpgformat, scans max. 600 pixel wide or 900 pixel high). Passport
photos may arrive later (by mail).
Va rugam sa luati in considerare ca, din considerente legale, ambarcarea este posibila numai atunci cand suntem in posesia in copie a tuturor
documentelor listate maisus – in cazuri urgente le puteti trimite prin curier, faxsauemail(informat jpg. 600x 900 pixeli ) .Pozele tippasaport pot fi
trimise mai tarziu (prin posta )
FamilyName
(Nume de familie)
GUGEAMAN First Name(s)
(Prenume)
DIONISIE DORU Rank
(Functie)
A/B
A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES (DOCUMENTEDE CALATORIE/MEDICALE)
Document Name (Desciption)
Titlul documentului ( Descriere)
Document Number
Numar Document
Country
Tara
Issue Place
Locul eliberarii
Issue Date
Data eliberarii
Exp. Date
Data expirarii
Passport ( Pasaport ) 053309633 ROMANIA CONSTANTA 10/11/2015 10/11/2020
Seaman's Book (national)(Carnet Marinar) 1794 CT ROMANIA ANR 21/11/2013 01/09/2016
Seaman's Book (Norwegian) (Carnet NIS)
Seaman's Book (Liberian)(Carnet Liberia)
Visa - UnitedStates (typeC1/D) (Viza USA) H7682095 ROMANIA Bucharest 03/12/2013 28/11/2018
Visa - Others (Work/ Resid. Permits) (AlteVize)
Medical ExaminationReport (Raport Medical) 2557 ROMANIA Spital Clinic CF 01/09/2015 01/09/2016
Drug & Alcohol Test (Test Drog/ Alcool)
Vaccination / YellowFever(Vaccin Febra Galbena) D 6104-3B ROMANIA P.H.A
Constanta
01/02/2011 01/02/2021
Vaccination against Cholera ( Vaccin Holera)
Passport Photos ( Poza de pasaport )
B. CERTIFICATES OFCOMPETENCY & ENDORSEMENTS, COURSECERTIFICATES
CERTIFICATE DECOMPETENTA & ENDORSEMENTS , CURSURI
- deck & engine certificates & endor-
sements (officers / ratings)
- electrical & reefer certificates
- cook & stewardcertificates
- radio certificates & endorsements
- safety training (surv.,fire,medical)
- tanker courses (oil, chem., gas)
- passenger vsl, roro,hazmat courses
- nav., deck, technical & management
courses (radar/ARPA, ISM, Marpol,
simulators, computer, weldingetc.)
- any flagstate certificates
Document Name (Description)
Titlul documentului (Descriere)
Document Number
Numar Document
Country
Tara
Issue Place
Locul
eliberarii
Issue Date
Data eliberarii
Exp. Date
Data expirarii
Personal Survival Techniques 00019252 ROMANIA CERONAV 20.01.2012 19.01.2017
BasicFire-Fighting 00019252 ROMANIA CERONAV 20.01.2012 19.01.2017
Medical FirstAid 00019252 ROMANIA CERONAV 20.01.2012 19.01.2017
Personal Safetyon and Social Responsibilities
Board Ships
00019252 ROMANIA CERONAV 20.01.2012 19.01.2017
Proficiency in Survival Craft and RescueBoats,
otherthan Fast Rescue Boats
00028328 ROMANIA CERONAV 24.01.2012 23.01.2017
Prevention of Pollution of the Marine
Environment – MARPOL 73/78
00012458 ROMANIA CERONAV 22.12.2011 22.12.2011
Transport and Handlingof Dangerous,
Hazardous and Harmful Cargoes
00012458 ROMANIA CERONAV 22.12.2011 21.12.2016
Maritime English and Problems of
Communication in Human Relationships
0006898 ROMANIA CERONAV 01.02.2012 31.01.2017
Tankers Familiarization 0007387 ROMANIA CERONAV 10.02.2012 09.02.2017
NATIONAL ENDORSEMENT 10822 ROMANIA CONSTANTA 15.02.2012 21.12.2016
TANKER ENDORSEMENT 18778 ROMANIA CONSTANTA 15.02.2012 31.12.2017
4. SEAFARER'S APPLICATION FORM - Page 3 of 4 - SEA SERVICE (LAST 10 YEARS)
(FORMULAR DE APLICARE PENTRU PERSONAL NAVIGANT - PAGINA 3 DIN 4 – SERVICIUL PE NAVE (ULTIMII 10 ANI)
Please indicate your sea service in the last 10 years as exact as possible - requiredare the actual sign-onandsign-off dates accordingtothe service certificates resp. seaman's book entries. To speed up processing kindly indicate phone
and/or fax numbers of your previous employers. Ship sizes are tobe indicatedin gross tons, total engine output in kiloWatt (1 kW= 1.34bhp)togo alongwith STCW limitations. Please be preparedtoprovide evidence forsea servicethat
cannot be confirmedby referencecheck. The informationprovidedmay be passedon to our clients andtoflagstate administrations to allow for verification of rank experience. Please use the European date format (DD.MM.YY).
Va rugam sa indicati ,cat mai exact posibil, ambarcarile din ultimii 10ani - obligatoriudatade ambarcare / debarcare asa cum reiese din Carnetul de marinar. Pentruprelucrare cat mai rapida va rugam sa indicati si numerele de telefon/fax
ai angajatorilor anteriori.Tonajul navei sa fie indicat in GT iar puteremotorin KW conform limitarilor STCW. Daca nupot fi confirmate prin verificari , fiti pregatiti sa aratati evidenteleambarcarilor. Informatiile date aici pot fi inmanate
clientilor nostrii si Administratiei Statului de Pavilion pentru a permite verificarea experinetei in functie . Va rugam sa folositi data in format European : ziua/luna/anul .
Family Name:
(Nume)
GUGEAMAN First Name(s):
(Prenume)
DIONISIE DORU Date of Birth:
(Data Nasterii)
25.11.1969
Vessel's Name
(Numele Navei)
Flag
(Pavilion)
GT
(GRT)
Kw
(Kw)
Ship Type
(Tipul Navei)
Eng.Maker
(Motor
Principal)
Rank
(Functie)
S/On Date
(Data
ambarcarii)
S/Off Date
(Data
debarcarii)
Employer (company to contact for reference)
Angajator (date de contact pentru referinte)
TOPAZ ROMANIA 15 2 X 306 SAR SCANIA A/B 17.04.2015 03.04.2016 ARSVOM,ROMANIA
KING FISHER HOLLAND 7000 2640 OIL TANK MAK A/B 08/01/2015 09/04/2015 JAMES FIHER
GSP ORION U.K. 1924 3600 PSV A/B 09/07/2014 08/11/2014 CORONA SHIPPING
EDT ARGONAUT CYPRUS 387 1000 TUG
SUPPLY
WICHMANN A/B 07/02/2014 23/06/2014 EDT SHIPMANGEMENT
MARINECO INDIA U.K 89.36 1750 TUG CATERPILAR A/B 06/09/2013 04/10/2013 GOOD WINDS/MARINECO U.K
ELA S DOMINIC
A
1559 441 GEN
.CARGO
MAN A/B 09/032013 14/08/2013 MERCURY SHIPPING
SAN LORENZO ITALY 6292 4000 OIL CHEM
ASFALT
WARTSILA A/B 15.03.2012 04.06.2012 TINECOMAR, ROMANIA (+40241-831032)
CHAITALI PREM ITALY 51255 13560 BULK MAN B&W A/B 20.05.11 31.10.11 SEAFARER SOLUTION, BUCHAREST
(+4031-4256178)
TOPAZ ROMANIA 15 2X306 SAR SCANIA A/B 20.11.10 19.05.11 ARSVOM, ROMANIA (+40241-601878)
SAN LORENZO ITALY 6292 4000 OIL CHEM
ASFALT
WARTSILA A/B 13.08.10 19.11.10 TINECOMAR, ROMANIA (+40241-831032)
HERCULES ROMANIA 3795 2X2426 AHTS MAN B&W A/B 05.01.09 11.08.10 ARSVOM, ROMANIA (+40241-601878)
CRISTAL ROMANIA 46 2X323 S/I VOLVO A/B 24.05.08 ARSVOM, ROMANIA (+40241-601878)
LS CHRISTINE GIBRALT
AR
5729 2X2460 OIL CHEM
TK
ROLLROYC
E
A/B 13.01.08 23.05.08 TRITON, ROMANIA (+40241-639300)
SYN MIRA ITALY 4066 4200 LPG GMT A/B 25.07.07 25.09.07 BLUEWATER NAV, ROMANIA (+40241-
611161)
SYN ALCOR ITALY 7605 4320 LPG MAK 9M A/B 11.02.06 07.07.06 BLUEWATER NAV, ROMANIA (+40241-
611161)
5. VALLE DI CASTIGLIA ITALY 25063 8500 PROD
CHEM TK
HYUNDAI A/B 09.06.05 13.12.05 BLUEWATER NAV, ROMANIA (+40241-
611161)
VALTELLINA ITALY 13086 6450 PROD
CHEM TK
SULZER A/B 14.05.05 09.06.05 BLUEWATER NAV, ROMANIA (+40241-
611161)
PORT LOUIS MARSHA
LL
24910 7860 OIL TK MAN B&W A/B 16.06.04 06.12.04 BARKLAV, ROMANIA
CREOLE MALTA 24332 10800 OIL TK SULZER O/S 18.07.03 01.03.04 SEAFARER SOLUTION, BUCHAREST
(+031-4256178)
ARMADA SPRINTER ANTIGUA 14885 11130 CONT - O/S 19.10.02 12.04.03 FAIRPLAY, ROMANIA
Date .2016
Data
Signature:DORU DIONISIE GUGEAMAN
Semnatura
