NOTE: A copy of this completed form will be forwarded to your email address after submission.

Applicants must be EU nationals and resident in the UK. Select division for application: Navigating Engineering

Title:		Mr Mrs Miss
Surname:
Forenames:
Place of Birth:
Nationality:
Height (m/cm):
Weight (kilos):
Address:
Postcode:
Telephone:
Mobile:
email:

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Next of Kin

Full Name:
Relationship:
Address: (if different from above)
Have any close relatives been to sea? (if so give name, rank and years of service)

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Medical History

Do you suffer from any visual handicap? (e.g. Colour Blindness) yes no

Have you ever suffered from Epilepsy or Nervous disorder ? yes no

Have you ever suffered from Asthma? yes no (If yes - give details below)

Please also list any other serious illness you have suffered from:

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Criminal Offences

Have you ever been arrested or convicted of any offence or crime? yes no If yes, please give details:

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Education

(give details of schools, colleges and/or universities attended over the last 5 years)

I authorise you to contact my school for relevant educational information. Tick box

	Name of School	Dates Attended	Address & Tel No.	Head Teacher
1
2
3

GCSEs or Standard Grades Must have 5 GCSEs at Grade C or above

Subject	Grade	Year sat
Mathematics		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
Physics*		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
English Language		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
English Literature		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
Other (Please list other GCSE subjects with grade and year sat)
*If you have undertaken a modular or integrated science course which includes physics please indicate whether this leads to a double G.C.S.E (by inputting 'DOUBLE' after your grade).

A Levels or Highers

Subject	Grade	Year sat
		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
		Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Exam sat but not passed Exam due this year
Further Education
(please enter details of Courses, Dates and Awards attained where applicable)

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Employment

(please enter details of all employment taken during or after education)

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Personal Statement

Please write a short account (about 200 words) stating why you wish to pursue a seafaring career:

Where did you hear about the Maersk cadet training scheme? Please specify:
	College/Careers advisor
	Family / friend
	Radio
	seacareers.co.uk website	other website
	Press/Posters - Please specify
	Careers Fair/Roadshow
	Other - Please specify

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References
Please give details of EMPLOYER/REFEREE who we may contact for reference if you have left school:
Name	Employer/Referee	Address	Occupation
	Employer Referee -
	Employer Referee -
	Employer Referee -
	Employer Referee -

By clicking the selection box below I confirm to the best of my knowledge that the information I have supplied above is true and accurate: