Position applied for: os-messboy

APPLICATION FORM

POSITION APPLIED FOR: os-messboy

Personal data

Family Name: OTDELIAKIN	Name: HENNADII	Father's name: HENNADIEVICH
Date of birth: 06.06.1983	Place of birth: UKRAINE	Nationality: UKRAINIAN
Marital status:	Children (name & DOB):
Address: UKRAINE,ODESSA citi,DALNITSKAYA 15 str. fl 58	Tel (including city code):	Mobile;
Next of kin and relationship: Married Wife:Family Name OTDELIAKINA Name: ANNA
Next of kin’s address: Address: UKRAINE,ODESSA citу,DALNITSKAYA 15 str. fl 58	Tel: [phone]
Inter. P’port No: ES210862	Issued: 08.SEP.14	Valid: 08.SEP.24	Place of issue:5112
Seaman's book No: AB546986	Issued: 03.JUN.15	Valid: 03.JUN.20	Place of issue:PORT ILYICHEVSK
Civil P’port No:KK423804	Place of issue: ILYICHEVSK citу	Date of issue: 25. Feb.00
USA visa No:	Issued:	Valid:	Place of issue:

Medical information

Medical examination	Issued:23.MAR.15	Valid:23.MAR.16	Weight, kg :80	Height, cm: 173
Drug & alcohol test	Issued:	Valid:	Eyes: blue	Hair: blonde
Yellow fever	Issued: 12.JUN.15	Valid:12.JUN.15	Overall size: 54	Safety shoes: 43

Name of marine school attended	Address of school	From	To	Degree of diploma
Education-training complex ADMIRAL	Bolshaya Arnautskaya 15 str.	01.APR.14	05.SEP.14

National License

Certificate of competency hold	Number	Issued	Valid	Place of issue
Диплом
Endorsement		02.JUN.15		Port of ILYICHEVSK

IMO	STCW Certificates	Number	Issued	Valid	Place of issue
	GMDSS Endorsement
	Carriage of dangerous and hazardous substances
1.08	ARPA (A-I/12, A-II/1, A-II/2, B-I/12)
	Personal safety (A-VI/1) (IMO 1.13, 1.19, 1.20, 1.21)		17.MAR.15	17.MAR.20	Ilyichevsk shiprepair yard
2.03	Advanced fire fighting (A-VI/3)
1.23	Prof. in survival craft (A-VI/2 p.1-4)
1.14	Medical first aid (A-VI/4-1)
1.15	Medical care (A-VI/4-2)
	Hazardous cargoes (B-V/4, B-V/5)
	Safety officer (ISM code)
	Crowd management (A-V/3)
	Bridge Team Management
	Training for person. serving onpassenger ships other than RO-RO pas.ships
	RoRo passenger (A-V/2-1,-2,-3,-4,-5)
	Ship security officer
	Ship handling arrangements
	DESIGNATED SECURITY DUTIES OF SHIPBOARD PERSONNEL		13.MAR.15	13.MAR.20	Ilyichevsk shiprepair yard

Dangerous cargoes certificates

1.01	Oil tank. familiarization (A-V/1)
1.02	Oil tank.Specialized training (A-V/1,p.9-14)
1.03	Chem. tank. familiarization (V/1)				.
1.04	Chem. tank. advanced (A-V/1,p.16-21)
1.05	LPG familiarization (V/1)
1.06	LPG advanced (A-V/1,p.23-34)

PREVIOUS SEA SERVICES (last 5 years)

Name of vessel	Year of built	Company	Flag	Type of vessel	DWT	Type of main engine	BHP	Rank	From Day,mont,year	To Day,month,year

Another States Seamen’s Books	Rank	Document No	Issued	Valid		Another States Certificates of competency	Rank	Document No	Issued	Valid
Liberia						Liberia
Panama						Panama

Please complete addresses of your previous employers for references

Company	«»	Tel:	Company		Tel:
Address		Address

Signature____________________ Date ______________­__ I understand, that my working contract will be canceled without notifying if any of submitted information and documents are voted as false.

FOR OFFICIAL USE ONLY English abilities: Good: Average: Poor:

(To be filled by Company’s authorised personnel) 10 9 8 7 6 5 4 3 2 1

Good spoken and written Understand basic instructions Do not understand basic instructions

Дата добавления: 2015-08-27