APPLICATION FORM PAGE 1

JOB APPLICATION FORM

APPLICATION FORM NO: _______

1. PERSONAL DETAILS
First name: Juan Carlos Family name: Vite C
Rank Applied: DECK SAILOR Date of readiness : 6/7/
Permanent Address:
jr. Miramar 149 zorritos Tumbes Peru

Nationality: peruvian Languages: spa

Phone number (Home): 958849237 Mobile phone number: 9690
E-mail address: karl2692@gmail.com Maritial Status: unm
Place of birth: zorritos - tumbes Date of birth (dd.mm.yyyy): 02 . 06
Age: 25 Number of kids (if any): no

COMPETENCY OF RANK: DECK RATING-DECK SAILOR

Unlimited ......... Limited ......... up to:

Height: 1.58 CM Home airport: lima

Weight: 68 KG Shoes & cloth sizes: 40 &
Color of hair: black Color of eye: bl
Name and Surname of next kin / relationship / address / phone number:

maria jesus correa cortez/ mother/ jr miramar149/ 969011682

2. TEST RESULTS
English Knowledge and Marlins Test Result:
Listening: Reading: General: Total:
Other tests (if applied) / name and results:
CES Test

3. EDUCATION HISTORY
DATES
NAME OF INSTITUTION/ SCHOOL COURSE ATTENDED / DEPARTMENT QUALIF
FROM TO
IE SIFREDO SUIGA QUINTO PRIMARY EDUCATION 4/1/1998 12/20/2003 1
IE SIFREDO SUIGA QUINTO SECONDARY EDUCATION 4/1/2004 12/20/2008 1
ENAMM COURSE
 APPLICATION FORM PAGE 2

4. TRAVEL DOCUMENTS AND CERTIFICATES

Document Number Place of Issue / Issuing Date of Issue
Name of Document Number Authority
General Documents:
Seamansbook CO-05485-MM CALLAO 5/22/2015
Passport MIGRACIONES
6295295 TUMBES
8/28/2014
Visa (USA: C1/D1)
Schengen Visa
GMDSS Certificate (GOC)
National License (STCW 95) DI-24758-01-MP DICAPI-CALLAO 3/12/2014
Medical Certificate
Yellow Fever Vaccination SERVIHEALTH
K5522-01 11/17/2014
TUMBES
for STCW 95:
Designated Security Duties 08198-2016 CENTRO PACIFICO 8/10/2016
Security Awaraness Certificate 08202-2016 CENTRO PACIFICO 8/10/2016
Security Related Familiarization
Personal Safety and Social Responsibility 08141-2016 CENTRO PACIFICO 8/8/2016
Personal Survial Course [95] 08141-2016 CENTRO PACIFICO 8/8/2016
Fire Prevention and Fire Fighting [95] 08141-2016 CENTRO PACIFICO 8/8/2016
Elementry Medical First Aid [95] 08141-2016 CENTRO PACIFICO 8/8/2016
Proficiency in Survival Craft [95]
Advanced Fire Fighting [95]
Medical Care [95]
Radar Observation Course [95]
Automatic Radar Plotting Aids (ARPA) [95]
Ship Security Officer [95]
Chemical Tanker Familiarization [95]
Chemical Tanker Operations [95]
Oil Tanker Familiarization [95]
Oil Tanker Operations [95]
Bridge Team Management [95]
ECDIS [95]
Ship Handling [95]

5. ADDITIONAL INFORMATION

Cargo carried: DECK RATING - DECK SAILOR

Trading areas: DECK AND BRIDGE

Nationalities sailed with: PERU-COLOMBIA

Cargo gears / loading systems: OFFSHORE
Ice navigation experience: NONE
Reason for leaving last employer: TERM OF CONTRAC
Others:
 APPLICATION FORM PAGE 3

PHOTO

Vite Correa
6/7/2017

jr. Miramar 149 zorritos Tumbes Peru

spanish
969011682
unmarried
02 . 06 . 1992
none

DECK RATING-DECK SAILOR

up to: Without limitation

lima peru
40 & size M
black
ber:

mother/ jr miramar149/ 969011682

EST RESULTS

CATION HISTORY

QUALIFICATION

17
15
 APPLICATION FORM PAGE 4

MENTS AND CERTIFICATES

Date of Issue Date of Expiry

5/22/2015 4/3/2018
8/28/2014 8/28/2019

3/12/2014 12/03/1018

11/17/2014 11/17/2024

8/10/2016 10/0872021
8/10/2016 8/10/2021

8/8/2016 8/8/2021
8/8/2016 8/8/2021
8/8/2016 8/8/2021
8/8/2016 8/8/2021

NAL INFORMATION

DECK RATING - DECK SAILOR

DECK AND BRIDGE

PERU-COLOMBIA
OFFSHORE
NONE
TERM OF CONTRAC
 APPLICATION FORM PAGE 3

6. SEA SERVICE DETAILS (Please give a full record starting with the last vessel on wh

M/E Power Joininig Date

Vessel Name Type Flag DWT Rank M/E Model kW (dd.mm.yyyy)

RM FRANCO CABOTAJE PERU 118.48 AB SAILOR CATERPILLAR D398 850BHP 8/3/2012

2100 BHP @
RM DON VICTOR 4 CABOTAJE PERU 489.64 AB SAILOR 02 GM - 16V - 149 1800RPM 12/15/2012
BHP
2100 BHP @
RM DON VICTOR 4 CABOTAJE PERU 489.64 AB DECK RATING 02 GM - 16V - 149 1800RPM BHP 4/12/2014
RM MISTRAL CABOTAJE PERU 313 AB DECK RATING JHANMAR 3600 HP 9/6/2014
PERU
OSV BARU INTI CABOTAJE 464 AB DECK RATING CUMMINS 1/10/2015
COMLOMBIA
PERU
OSV BARU PACIFICO CABOTAJE 447 AB DECK RATING CATERPILLAR 4/16/2015
COMLOMBIA
PERU
OSV BARU INTI CABOTAJE 464 AB DECK RATING CUMMINS 4/23/2016
COMLOMBIA
RM MISTRAL CABOTAJE PERU 313 AB DECK RATING JHANMAR 3600 HP 12/6/2016
 APPLICATION FORM PAGE 3
FOR TANKER OFFICERS MATRIX ONLY:
Total Tanker Experience:
Total Ch. Tanker Experience:
Total Experience in current rank: 4Y 6M 24 D

*I hereby certify that the statements and information in this application form are true and correct to the best of my knowledge and belief, and I authorize the "Harren & Partner Shi
application form and any attachments submitted with it.

SIGNED BY AND SIGNATURE DATE:

JUAN CARLOS VITE CORREA. DNI 47177044 6/8/2017

CHECKED AND ACKNOWLEDGED BY:

FOR OFFICE USE
ONLY:
 APPLICATION FORM PAGE 3

tarting with the last vessel on which you served)

Company Information
Disembarkation Date Duration of
(dd.mm.yyyy) Contract
Owners/Ship Managers name Contact details & name of person/dept. in
charge
12/13/2012 4 M 10 D MULTIMPEX S.A.C SCAR SALDOVAL PEVES/ CAPTAIN
4/11/2014 15 M 16 D COMPIA NAVIERA NATALIA JULIO JUAN MARTINEZ VILLAVICENCIO
JUAN CARLOS FERNANDES ELIAS/ JEFE DE
6/30/2014 1 M 18 D COMPIA NAVIERA NATALIA OPERACIONES. PHONE 981200252
BARU OFFSHORE SUCURSAL DEL
1/8/2014 29 M D PERCY IVAN ZAPATA MENDOZA/ CAPITAN
PERU
BARU OFFSHORE SUCURSAL DEL
4/9/2015 M D ARMANDO ARTICA UCHUYA/CAPITAN
PERU
BARU OFFSHORE SUCURSAL DEL
4/22/2016 M D ARMANDO ARTICA UCHUYA/CAPITAN
PERU
BARU OFFSHORE SUCURSAL DEL
11/29/2016 M D ARMANDO ARTICA UCHUYA/CAPITAN
PERU
BARU OFFSHORE SUCURSAL DEL
2/27/2017 M 21 D CARLOS BROMLEY VARGAS/ CAPITAN
PERU
DARWIN CASTILLO HIDALGO/ JEFE DE
M D OPERACIONES. PHONE 981538990
M D
M D
M D
M D
M D
M D
M D
M D
M D
M D
M D
M D
M D
M D
M D
 APPLICATION FORM PAGE 3

and I authorize the "Harren & Partner Ship Management Pte. Ltd." to investigate all statements or other information contained in this

DATE: PLACE:
6/8/2017 TUMBES PERU

Issued for and on behalf of Harren & Partner