• Did you suffer, or presently suff

• Did you suffer, or presently suffer from any disease likely to render you unfit for services at sea or likely to endanger the health of other persons on board?
If yes, please provide details _________________________________________________¬¬¬¬¬¬¬¬¬¬¬_______
_______________________________________________________________________________ 0YES 0NO

• Did you suffer any accident, which rendered you temporary and/or partially disabled? 0YES 0NO

• Did you ever undergo psychiatric treatment 0YES 0NO

• Are you addicted to alcohol or drugs of any kind? 0YES 0NO

I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organization.
Place___________________________ Date ___________________________ Signature ______________________________
For Office Use
Initial assessment of applicant for further recruitment
Comments

Результаты (русский) 1:

• Did you suffer, or presently suffer from any disease likely to render you unfit for services at sea or likely to endanger the health of other persons on board? If yes, please provide details _________________________________________________¬¬¬¬¬¬¬¬¬¬¬_______ _______________________________________________________________________________ 0YES 0NO• Did you suffer any accident, which rendered you temporary and/or partially disabled? 0YES 0NO• Did you ever undergo psychiatric treatment 0YES 0NO • Are you addicted to alcohol or drugs of any kind? 0YES 0NOI hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers’ database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers’ organization.Place___________________________ Date ___________________________ Signature ______________________________Для использования в офисеПервоначальная оценка заявителя для дальнейшего набораКомментарии

Результаты (русский) 3:

- Вы страдать, или в настоящее время страдают от любой болезни, вероятно, сделать вам непригодным для услуг на море или создать угрозу здоровью других лиц, находящихся на борту?
Если да, то просьба представить подробную информацию о _________________________________________________¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬_______
_______________________________________________________________________________ 0 да 0 нет

( вы страдали от каких-либо аварии,Который вы временных и/или частично отключена? 0ДА 0нет

- действительно ли вы пройти психиатрическое лечение 0да 0нет ветровому ( вы употребляли алкоголь или наркотики любого рода? 0ДА 0нет

настоящим заявляю, что приведенные выше факты и информацию, правдивой и точной.