CRW-01

SEAFARER’S APPLICATION FORM Issue No.2

Dec 14

Present Rank: AB Rank applied for: AB

Name in full: Deniss Sumilovs

Father’s name: Mother’s name:

Birth place and date: Ventspils 26.11.1981 Nationality: Latvian
Address: Riga Vilipa str.8-108
Phone: +371 28240273
Next of kin / Relationship / Address: Anna Sumilova/Wife/Riga Vilipa str.8-108

Height: 170 Weight: 86

Marital status: Married Suit size: 52-54 Shoe size: 43

No. of Children:
Last medical Yellow fever U.S Visa Date of availability:
examination date: 29.03.2021 vaccination date:       expiry date: 02.07.2024 15.01.2023

DOCUMENTS No Issued Expire Country Issue

License National 1077/21 10.03.2021 08.03.2026 Latvia Grade: Able seafarer
deck
License Other                         Grade:      
Seaman Book Nat. 0262727 20.05.2015 20.05.2025 Latvia
Seaman Book Other                        
Passport LZ4116485 24.01.2022 23.01.2032 Citizenship: Latvian

ENGLISH: GOOD x AVERAGE POOR Suggestions:      

CERTIFICATES REG. NO. OF CERT ISSUED EXPIRE

License / COC 1559/20 05.05.2020 04.05.2025
National Endorsement                  
Basic Safety VI/1-1 up to 1-4 LA Nr.09025/22 02.03.2022 02.03.2027
General Tanker Familiarization A-V/1 Par 1-7       15.03.2002      
Advanced Oil Tanker Cert. A-V/1 Par 8-14                  
G.M.D.S.S. IV/2                  
Medical care A-VI/4                  
ARPA A-II/1                  
Proficiency In Survival C&R Boats VI/2-1 LA Nr.09039/22 02.03.2022 02.03.2027
Advance Fire Fighting VI/3-1                  
Medical First Aid VI/4-1                  
Ship Security Officer (SSO) VI/5                  
Bridge Resource Management (BRM)                  
Engine Resource Management (ERM)                  
Ship Safety Officer (SSOC) LA Nr.32080/13 07.08.2013      
Risk assessment                  
Incident investigation                  
Ship's handling and maneuvering                  
Vetting inspection course                  
Antipiracy seminar                  
In-house training                  
Marlins (maritime english)                  
ECDIS                  
MLC regulation 3.2.2 MLC reg. 3.2.2                  
                       
                       
                       

Guidance : To be filled by all seafarers as applicable Eff. Date: July 2019 /

Rev.01
Vessel File: - Page 1 of 3
 CRW-01
SEAFARER’S APPLICATION FORM Issue No.2
Dec 14

Previous Services at other companies:

Eng.
MANAGERS / Reason for
TYPE VESSEL’S NAME RANK D.W. Type / PERIOD OF SERVICE
OWNERS Sign off
B.H.P
Oil/ Baltix Sun II INC AB 40000       23.07.201 18.11.2015 End of
chem Shipmanagement 5 contract
Oil/ Leopard Moon LSC AB 50000       26.04.2016 19.09.2016 End of
Chem Shipmanagement comtract
Oil/ ANCE LSC AB 50000       05.03.2017 11.08.2017 End of
chem Shipmanagement contract
Oil/ STI Esles II Astor AB 50000       26.12.2017 11.06.2018 End of
chem Shipmanagement contract
Oil/ STI Camden Astor AB 40000       13.10.2018 18.04.2019 End of
chem Shipmanagement contract
Oil/ STI Astor AB 40000       13.08.2019 02.02.2020 End of
chem Hammersmith Shipmanagement contrarct
Oil/ STI Camden Astor AB 40000       18.05.2020 27.11.2020 End of
chem Shipmanagement contract
Oil Walleye Prime Marine AB 75000       08.05.2021 09.11.2021 End of
tank contract
Oil Baltic Swift INC AB 40000       29.03.2022 06.10.2022 End of
tank Shipmanagement contract
   Oil Bowfin     Prime                          End Of
tank  Marine  AB   75000 17.01.2023  02.06.2023  Contract   
     

APPLICANT (NAME): Deniss Sumilovs SIGNATURE DATE 01.04.2021

Services with MM Marine Inc:

VSL VESSEL D.W. DURATION OF TOTAL RESON OF

RANK Remarks
TYPE NAME B.H.P. EMPLOYMENT SERVICE SIGN OFF
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     
                                                     

CREW MANAGER APPLICATION REVIEW (application’s validity to be reviewed prior each employment)

Guidance : To be filled by all seafarers as applicable Eff. Date: July 2019 /

Rev.01
Vessel File: - Page 2 of 3
 CRW-01
SEAFARER’S APPLICATION FORM Issue No.2
Dec 14

NAME DATE SIGNATURE

                 

                 
                 
                 
                 
                 
                 
                 

Guidance : To be filled by all seafarers as applicable Eff. Date: July 2019 /

Rev.01
Vessel File: - Page 3 of 3
 CRW-01
SEAFARER’S APPLICATION FORM Issue No.2
Dec 14

INTERVIEW FORM (As per attached interview check list)

ONLY for the accepted applicants. Interview will be carried out by the Department Managers or their deputies.

SEAFARER’S NAME:       RANK:       INTERVIEW DATE:

                 

OFFICERS ARE TO BE INTERVIEWED ON SPECIFIC TOPICS. INTERVIEWERS TO SIGN BELOW AS APPLICABLE:

COMPANY DEPARTMENTS
CREW NAME/SIGNATURE ACCEPTED YES NO
COMMENTS
DATE
DPA ACCEPTED YES NO
NAME/SIGNATURE
COMMENTS
DATE

TECHNICAL ACCEPTED YES NO

NAME/POSITION/SIGNATURE
COMMENTS
DATE

OPERATIONS NAME/POSITION/SIGNATURE ACCEPTED YES NO

COMMENTS
DATE

Note: 1) Any comments shall be recorded in the relevant fields 2) Final approval as per OM-04

INTERVIEW CARRIED OUT: AT HEAD OFFICE THROUGH VIDEOCONFERENCE

CERTIFICATES’ AUTHENTICITY CHECK Completed by the Crew Manager, when recruitment is conducted directly by
the Company.
Completed by the Manning Agent, when the recruitment is conducted by the Manning Agency and verified by the Crew Manager.
Authenticity check conducted for certificates:

CONDUCTED BY MANNING AGENT (Name/Position)      

DATE       RESULTS Satisfactory Unsatisfactory
VERIFIED BY CREW MANAGER (Name)
DATE       RESULTS Satisfactory Unsatisfactory

REFERENCES/INFORMATION, ETC. FROM PREVIOUS EMPLOYERS (to be completed by Crew Manager/Manning

agent)      
     
     

MEDICAL EXAMINATIONS TO BE CONDUCTED PRIOR TO SEAFARER’S ENGAGEMENT

MEDICAL EXAMINATIONS AND D&A TEST COMPLETED SATISFACTORY? YES NO

Guidance : To be filled by all seafarers as applicable Eff. Date: July 2019 /

Rev.01
Vessel File: - Page 4 of 3
 CRW-01
SEAFARER’S APPLICATION FORM Issue No.2
Dec 14

Guidance : To be filled by all seafarers as applicable Eff. Date: July 2019 /

Rev.01
Vessel File: - Page 5 of 3