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      NAME: *

      CITY:

      ZIP CODE:

      SURNAME: *

      REGION / STATE:

      COUNTRY:*

      DATE OF BIRTH:*

      PLACE OF BIRTH:

      E-MAIL: *

      CITIZENSHIP:

      DATE AVAILABLE:

      PHONE NUMBER: *

      PHONE NUMBER2:

      Your sea-going experience (last 5 years data):

      NN

      IMO

      Vessel's Name

      Vessel's type

      DWT (3 to 6 digit number)

      Engine Type

      HP or KW
      (3 to 7 digit number)

      Position / Rank

      From DD/MM/YYYY

      Till DD/MM/YYYY

      Crewing Agency

      Ship manager / Shipowner

      1

      2

      3

      4

      5

      Please provide any additional information that you think the employer should know