APPLICATION FORM
Position Applied for
A/B
Alternative
Family name
********
Given name
Roman
Fathers name
Vladimirovich
Date & place of birth
********** Donetsk r-n, Ukraine
USA visa valid till
22.**************
Height 188 . cm
Weigh 110. kg
Overall size 56 .
Shoes size45…
Addres
Street
Ogorodnaya,8
City/Country
Belgorod-Dnestrovskyi, Odessa r-n, Ukraine
Airport(s)
Tel:
Mobile
****************
E-mail:
********************
Next of Kin
Name / Relationship
******** Vladimir/Father
Date of birth
**********
Street
Same me
City/Country
Same me
Tel
*************
Mobile
E-mail:
Name of School / Academy attended
Address
Dates attended
Type of Degree & Diploma
From
To
Received upon Graduation
Marine fishing industry college
Belgorod-Dnestrovskyi,
2002
2006
Marine academy
Odessa
2006
2012
Navigator
SEA SERVICE (from latest to previous)
NAME of VESSEL | Position | Vessel’s type | Engine type | Flag | Company | Period of service |
DWT | HP | Year of built | Crew Agent | |||
Hyundai | O/S | Car Carrier | Hyundai | Liberia | Zodiac | S/on 04.06.07 |
12516 | 14400 | 1987 | S/*********.07 | |||
Yacht Express | O/S | Yacht Carirer | Wartsila | Netherlands | Dockwise(Univis) | S/on********** |
9348.4 | 2*8700kW | 2007 | S/*********.08 | |||
Super Servant 3 | O/S | Semi Submersible Heavy Lift | Wartsila | Netherlands | Dockwise(Univis) | S/on04/08/09 |
10224 | 8503 | 1982 | S/*********/10 | |||
Ocean Voyager | A/B | Multi-Purpose Dry Cargo | Kingstown | Kaalbye Shipping Ukraine | S/on ********** | |
7249GRT | 6830HP | 1994 | S/off ********** | |||
Orient Tribune | A/B | Bulker | Limassol | InterOrient | S/on 11.11.15 | |
23426t | S/*********.16 | |||||
S/on | ||||||
S/off | ||||||
UNISTAR | A/B | DRY CARGO | S/on********** | |||
4997 | 2652 | Riga | Unimars | S/off ********** | ||
S/on | ||||||
S/off | ||||||
S/on | ||||||
S/off |
Above information is to the best of my knowledge and correct. (to be signed by the person, who completed the form)
Date ********** . Signature .
DOCUMENTS / VISAS
Type of documents | Place of issue | Serial Number | Issue Date | Expiration date | |
Seaman’s book (National) | Odessa | AB524027 | 08/01/14 | 08/01/24 | |
Travel. Passport | Odessa | ER049252 | 30.01.14 | 30.01.24 | |
USA Visa | |||||
Certificate. of Competency | Avant Ilyichevsk | 017329 | 21.08.06 | ||
Endorsement | Odessa | 1************ | 19.08.14 | NO Expiration | |
Certificate. of Competency | |||||
Endorsement | |||||
GMDSS : | |||||
GMDSS Endorsement |
********** CERTIFICATES / OTHER CERTIFICATES
CERTIFICATE | Issued on | Valid till | ||||
Basic Safety Training (VI/1) | 24.07.18 | 24.07.23 | ||||
Proficiency in survival craft & rescue boats (VI/2) | 30/07/18 | 30/07/23 | ||||
Advanced fire fighting (VI/3) | 21.03.14 | 21.03.19 | ||||
Medical First Aid (VI/4) | ||||||
Medical Care (VI/4) | ||||||
Dangerous and Hazardous Cargoes (B-V/b ,B-V/c) | 26/05/17 | 26/05/22 | ||||
Tanker familiarization | ||||||
Oil advanced (V/1) | ||||||
Chemical advanced (V/1 ) | ||||||
Gas advanced (V/1) | ||||||
IGS (Inert gas system) | ||||||
COW (Crude oil washing: IMO model ***********) | ||||||
Ship Security Officer (VI/5) | ||||||
Ship Safety Officer (ISM Code) | ||||||
AMOS for WINDOWS | ||||||
Engine Resources Management | ||||||
Bridge Team Management (IMO-model ***********) | ||||||
Ship’s Handling (B-V/A) | ||||||
Radar Navigation (Radar & ARPA) | ||||||
ECDIS | ||||||
Cargo & Ballast handling | ||||||
Dynamic *************, 3 | ||||||
VACCINATION | ||||||
Yellow Fever | Date of vaccination: *************.09.2024 | |||||
Hepatitis A, B | Date of vaccination: | |||||
Date of readiness / Wage expectation and -Last salary |