Adam Storma has applied for the position of Other Position. He provides his personal details including his date of birth in Gdynia, Poland. He lists his current address in Gdynia and contact information. He also provides details on his family, education and qualifications, languages, medical examinations, safety training and certifications. Finally, he includes his extensive sea service history between 2012-2014 serving as a chief cook or second cook aboard various vessels. He provides references from his current and previous employers.

1. APPLICATION FOR POSITION AS OTHER POSITION (IF ANY)
1. PERSONAL DETAILS
TITLE MR/MRS/MISS SEX MALE X FEMALE
SURNAME STORMA
FIRST NAME ADAM OTHER NAMES
DATE OF BIRTH Date -12.01.1974 PLACE OF BIRTH GDYNIA
NATIONALITY POLAND MARITAL STATUS married
HEIGHT (CM) 181 WEIGHT (KG) 125
NEAREST INTERNATIONAL AIRPORT: GDN (GDANSK)
2. ADDRESS ADDRESS (TEMP.) FROM/TO:
NO & STREET RYDZOWA 9/1 NO & STREET
CITY GDYNIA CITY
POST CODE 81-081 POST CODE
COUNTRY POLAND COUNTRY
TEL. NO. TEL. NO.
MOBILE (+48) 514 305 289 MOBILE
E-MAIL kartezz@gmail.com E-MAIL
SKYPE ID kartez FAX
3. NEXT OF KIN
FULL NAME SYLWIA STORMA RELATIONSHIP WIFE
ADDRESS RYDZOWA 9 / 1 181-081
APPLICATION FORM

2. CITY GDYNIA COUNTRY POLAND
TEL. NO. MOBILE (+48)509836439 FAX NO.
4. CHILDREN
NAME OF CHILD DATE OF BIRTH SEX
BARTOSZ STORMA 19.06.2009 M X F
AGATA STORMA 27.04.2006 M F X
M F
5. TRAVEL DOCUMENTS
TYPE DOCUMENT NO. ISS.DATE EXP. DATE ISS. BY (AUTHORITY) PLACE OF ISSUE
PASSPORT ED8987681 18.06.2012 18.06.2022 GDYNIA/POLAND
SEAMANS BOOK 0197595 19.01.2000 GDYNIA/POLAND
OTHER SEAMANS
BOOK
OTHER SEAMANS
BOOK
OTHER SEAMANS
BOOK
6. VISAS
US C1/D VISA
OTHER VISA
OTHER VISA
OTHER VISA
7. EDUCATION
SCHOOL NAME college in Koscierzyna FROM 2002 TO 2004
SCHOOL NAME School of Hotel and Catering FROM 1989 TO 1992

3. 8. PROFESSIONAL QUALIFICATION / CERTIFICATE OF COMPETENCY (Include any other flag
endorsements that you hold)
CERTIFICATE NAME NUMBER ISSUE DATE
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
Cook crtificate
009681-
37-01
23-12-1999
DANGEROUS CARGO ENDORSEMENT NUMBER ISSUE DATE EXPIRY DATE
PETROLEUM
CHEMICAL
GAS
9. LANGUAGES
ENGLISH FLUENT GOOD x FAIR POOR
GERMAN FLUENT GOOD FAIR POOR
FRENCH FLUENT GOOD FAIR POOR
RUSSIAN FLUENT GOOD FAIR x POOR
10. MARLINS/TOSE (Required for all whose native language is not English)
TEST LEVEL (Management,
Operational, Support)
ISSUED
DATE
RESULT %
ISSUED BY
(AUTHORITY)
ISSUED AT
ISF Merlins English
Language(test for seafares)
8.06.2011 71 OSM POLAND GDYNIA POLAND
TOSE
11. VACCINATIONS
NAME
ISSUE
DATE
EXPIRY DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
YELLOW FEVER 08.10.2010 08.10.2020 MEDICAL POLAND GDYNIA
CHOLERA 08.10.2010 08.10.2020 MEDICAL POLAND GDYNIA
TYPHOID 08.10.2010 08.10.2020 MEDICAL POLAND GDYNIA

4. TETANUS 08.10.2010 08.10.2020 MEDICAL POLAND GDYNIA
HEPATITIS A 08.10.2010 08.10.2020 MEDICAL POLAND GDYNIA
POLIO 08.10.2010 08.10.2020 MEDICAL POLAND GDYNIA
12. SAFETY CLOTHING
BOILERSUIT SIZE BOOTS SIZE
2XL 46
13. MARINE COURSES
COURSE NAME
CERTIFICATE
NUMBER
ISSUE DATE
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
BASIC SAFETY TRAINING
Gum-5425-075817-
4736/2012
2012-03-27
2017-03-
27
GUM GDYNIA
PST OR BSS
BASIC FIRE FIGHTING
Gum-5425-075817-
4736/2012
2012-03-27
2017-03-
27
GUM GDYNIA
ADV. FIRE FIGHTING
ELEMENTARY FIRST AID
Gum-5425-075817-
4736/2012
2012-03-27
2017-03-
27
GUM GDYNIA
MEDICAL FIRST AID
GUM5421075817147/201
0
2010.01.07 GUM GDYNIA
MEDICAL CARE ON BOARD
SHIP
PERS. SAFETY & SOC. RESP.
Gum-5425-075817-
4736/2012
2012-03-27
2017-03-
27
GUM GDYNIA
PROF IN SURVIVAL CRAFT
GUM5419-075817-
4744/2010
2010.09.28 GUM GDYNIA
FAST RESCUE BOAT(STCW95)
CROWD MGMT
CRISIS MGMT
G.M.D.S.S.
NARAST/ARPA(Operational)

5. NARAST/ARPA(Management)
ECDIS
HAZMAT
OIL TANKER FAM.
ADVANCED OIL TANKER
CHEMICAL TANKER FAM.
ADVANCED CHEM. TANKER
GAS TANKER FAM.
ADVANCED GAS TANKER
CRUDE OIL WASHING
INERT GAS PLANT
SHIP SAFETY OFFICER
SHIP SECURITY OFFICER
SECURITY AWARENESS
GUM13500758179093/20
14
2014.01.29 GUM GDYNIA
DESIGNATED SECURITY
DUTIES
GUM13510758179049/20
14
2014.01.29 GUM GDYNIA
BRIDGE TEAM MANAGEMENT
BRIDGE RESOURSE MGMT
DP BASIC/INDUCTION
DP ADVANCED/SIMULATOR
DP OPERATOR
AIS
14. OFFSHORE COURSES
ITSO
FRC BOATMAN
FRC COXWAIN
DAUGHTER CRAFT COXWAIN
BOSIET 045700300414192405 28.04.2014 29.04.2018
OPITO-
CODE5700
ABERDEEN
HUET 27858/1089/10 11.10.2010 11.10.2013 GUM GDYNIA
EBS
HLO

6. OEHTM
CAA
COMMAND & CONTROL
ADVANCED MEDICAL AID
15. MEDICAL FITNESS CERTIFICATE
NUMBER ISSUE DATE
EXPIRY
DATE
ISSUED BY
(AUTHORITY)
ISSUED AT
ENG1
INTERNATIONAL 302 02.05.2014 01.05.2016
MEDICAL
OFFICER
GDYNIA
OTHER
OGUK 2007/1044 02.05.2014 01.05.2016
MEDICAL
OFFICER
GDYNIA
LIBERIA 302/12.08.2013 12.08.2013 12.08.2015
MEDICAL
OFFICER
GDYNIA

7. 18.SEA SERVICE DETAILS
COMPANY NAME RANK VESSEL NAME
SIGNED
ON
SIGNED
OFF
VESSEL TYPE* G.R.T. D.W.T. ENGINE TYPE BHP KW
BMS(Bernhad Schulte
Shipmanagment)
OSM
Chife
cook/camp
Boss
2ND-COOK
Borwin Beta
SKANDI
CONSTRACTOR
14.09.2014
27.062014
17.09.2015
20.07.14
Wind Platform
CONSTRACTO
R
OSM 2ND-COOK
SKANDI
CONSTRACTOR
05.05.14 02.06.14 CONSTRACTO
R
OSM CHIFE COOK KL SANDEFJORD 01.02.14 19.02.14 PSV
OSM CHIFE COOK ER TROMSOE 15.10.13 10.12.13 PSV
OSM CHIFE COOK ER TROMSOE 25.06.13 19.08.13 PSV
OSM CHIFE COOK ER TROMSOE 05.03.13 30.04.13 PSV
OSM CHIFE COOK ER GEORGINA 07.01.13 05.02.13 PSV
Western Geco from Vship CHIFE COOK Geco Topaz 19.06.12 04.07.12 GAN
CHIFE COOK
OSM CHIFE COOK KL Saltfjor 04.05.2012 06.06.2012 AHTS
Western Geco from Vship CHIFE
COOK-
BACKER
Geco Topaz 06.12.2011 31.01.2012 GAN
OSM CHIFE COOK ER HAGESUN 16.08.2011 14.09.2011 PSV
OSM CHIFE COOK KL BARENTSFJORD 28.06.2011 21 .07.2011 PSV
OSM CHIFE COOK KL BARENTSFJORD 23.03.2011 02.06.2011 PSV
REFERENCE CONTACT DETAILS
COMPANY NAME Stanshiping BMS
ADDRESS

8. +48 501 267 733 +4940822265527
FAX/E-MAIL lukasz.jamroz@stanship.com.pl Sara.Hiller@bs-shipmanagement.com
CONTACT PERSON Lukasz Jamroz Sara.Hiller