Date: .......................................Ready for employment : .......................................E- mail: .......................................

1. Family name ..............................., First name .........................., Middle name ................................2. Date of birth ...................................... 3. Place of birth: ...................................................................4. Nationality ........................................... Country of birth: .................................................................5. Identity card № ..................................., Date of issue ......................................................................Place of issue ............................................, ID № (ЕГН) .....................................................................6. Height ................, Weight .................., Eyes color ........................, Hair color: ...............................Overall №: ................., Shoes №: ..................., Preferred vessels: .....................................................7. Marital status ................................................, Nearest Airport: ........................................................8. Present address .............................................................................................................................................................................................................................................................................................9. Phone number(s) .............................................................................................................................10. Next of kin / full name / ....................................................................., Phone ...............................Address ...................................................................................................., Relations: ........................11. Have you any health problems: ...................................................................................................................................................................................................................................................................12. Education: ......................................., Institution: ........................................................................... Diploma № .........................., issued on: ............................, Speciality: ........................................ Period of study: from .......................... to ......................13. Previous sea servise in years: .....................................................................................................................................................................................................................................................................14. Do you speak English fluently: ........................ Read: ......................... Write: ...............................

Passed English test: ....................., Percentage: ............, Other tests: ..........................................

phone: + 359 52 33 54 55 mobile: + 359 899 145 745phone: + 359 52 33 55 03 mobile: + 359 890 145 700mobile: + 359 887 272 672 mobile: + 359 899 145 700

Application Form

RANK APPLIED FOR: .................................

photo

LIL - 12 v.6/2018 fr 01/02/01

58, Debar str., floor 5, Varna 9000, BULGARIAe-mail: crewing@lil-12.com, www.lil-12.com

15. What other languages do you speak: .............................................................................................

17. Seaman's book № ................................ Issued on ......................... Expire on ..............................18. International passport № ...................... Issued on ......................... Expire on ..............................

20. Flag Endorsements (if any)

21. STCW Certificates

LIL - 12 v.6/2018 fr 01/02/01

COUNTRY LICENCED AS CERTIFICATE NUMBER DATE OF ISSUE

CERTIFICATIONSBasic Safety TrainingProficiency in Survival Craft

Safe Oper. And Maint. of PS In Excess 1000V

Proficiency in Medical First Aid

SSO / SDSD / SSA

Competency in Advanced Fire Fighting

Medical Care

Main And Aux Machinery Operation And ACS

Bridge/Engine Res.Management and Teamwork

ECDIS & AISBasic Train.In Oil And Chem.Tanker Cargo Oper.

Fast Rescue Boat

CERTIFICATE NUMBER DATE OF ISSUE

Adv.Training In Chem.Tanker Cargo OperationsAdv.Training In Oil Tanker Cargo Operations

MSRC, Radar&Operational use of A.R.P.A

16. Seafarer's passport № .......................... Issued on ......................... Expire on ..............................

COUNTRY LICENCED AS CERTIFICATE NUMBER DATE OF ISSUE

19. Certificate Of Competency

COUNTRY LICENCED AS CERTIFICATE NUMBER DATE OF ISSUE

HAZMAT

Safety Officer

Marine Environmental Awareness

HUETDP Certificate

HLOSlingman / Banksman Course

PeriodFrom To

RankVessel

Name Type GTMain Engine

Type KWEmployer

IMO

22. Previous Sea Service (last 10 contracts, if any)

LIL - 12fr 01/02/01

v.6/2018

RELATIVESMother: ...................................................................................... Date of Birth: ....................................Father: ...................................................................................... Date of Birth: ....................................Brother: ................................................................................................................................................Sister: .................................................................................................................................................Wife: ..................................................................................................................................................... Date of birth: ............................................... Place of birth: ..........................................................Children: 1. ....................................................................................................................................... 2. ....................................................................................................................................... 3. .......................................................................................................................................

Military service: .............. Period: from ......................... to ....................... Position: ............................Ex-company name: ..............................................................................................................................Address: ............................................................................., Phone: ....................................................PIC: ...................................................................................., Phone: ....................................................

..............................................................................................................................................................

..............................................................................................................................................................

..............................................................................................................................................................

..............................................................................................................................................................

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Information about the previous experience of the seafarer

..............................................................................................................................................................

..............................................................................................................................................................

..............................................................................................................................................................

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Signature: ......................................

LIL - 12 v.6/2018 fr 01/02/01

23. Diplomas and certificates for fitters, cooks, stewards ..................................................................... ......................................................................................................................................................24. Visas: - USA Visa: C1/D , B1/OCS, Issue date: .........................., Expiry date: ......................... - Other: .........................................., Issue date: .........................., Expiry date: .........................

25. Vaccines: - Yellow Fever, Issue date: .................................... - Other vaccinations: ..................................................................................................................

..............................................................................................................................................................

CONSENT FORM

Consent to the release of information under the provisions of the Data Protection Regulation (EU)

2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such

data. I, ___________________________________________________________ hereby consent to the collection, processing, storing, transmission and use by LIL-12 Ltd. of my personal data which includes, but is not limited to: passport and seaman's book details, qualifications and training records, medical certificates, drug and alcohol test results, contracts of employment, data related to payment of wages, bank details required for the transmission of home allotments and final wage accounts, information about hours of work and rest, and any other information that LIL-12 Ltd. may legally be entitled to collect in order to enable LIL-12 Ltd. to perform its contractual obligations in respect of the Seafarer's recruiting process and employment. I understand my right to request access to such personal data which is being kept by LIL-12 Ltd., as well as my right to request correction or rectification of such information. Furthermore, I understand my responsibility to provide accurate and up-to-date information to LIL-12 Ltd. Subject always to any mandatory requirement of any law, LIL-12 Ltd. may provide my personal details for legitimate purposes to governments, immigration and other competent authorities and/or, as may be required by law, ship's agents, travel agents, airlines, port state control, police, flag states, ship's charterers and operators, and clinics and doctors conducting pre-employment medical examinations, as may be required by the relevant party, including but not limited to: by means of client portals, secure websites and/or internet secure sites. Without prejudice to the data protection laws allowing such transfer of information, in the case of emergencies, I give explicit consent to the Employer, LIL-12 Ltd. and/or their servants or agents to provide personal data, including medical information, to ship's agents, shore side doctors, the ship owner, managers, charterers, insurers and advisors, as may be necessary for the purposes of dealing with said medical emergency. These provisions do not restrict LIL-12 Ltd. from disclosing personal data where required or allowed to do so by law. This includes cases of national or public security, commission or prevention of criminal offences and/or legal proceedings. I understand my right to withdraw this consent at any time except cases governed by law when keeping of my data is compulsory. I am aware that this may result in an inability of LIL-12 Ltd. to fulfill its obligations in respect of the recruiting process. I confirm that I have read and understood the contents of this consent form. Full name: ______________________ Signature: _______________________ Date: _______________________