Position applied for: Deck cadet / Ordinary seaman

APPLICATION FORM

POSITION APPLIED FOR: Deck cadet / Ordinary seaman

Personal data

Family Name: Gross	Name: Viktor	Father's name: Yevgen
Date of birth: 09.05.1991	Place of birth: Ukraine	Nationality: Ukrainian
Marital status: single	Children (name & DOB):
Address : 114 Kapitana Kuznetsova str. Ap 58	Tel (including city code): 38 048 711 57 07	Mobile; 38 063 061 66 01
Next of kin and relationship: Gross Lyudmyla mother
Next of kin’s address : 114 Kapitana Kuznetsova str. Ap 58	Tel: [phone]
Inter. P’port No: EK 26 68 09	Issued: 16.06.2009	Valid: 16.06.2019	Place of issue: ODESSA
Seaman's book No: AB 54 64 02	Issued: 24.03.2015	Valid: 24.03.2020	Place of issue: ILYICHEVSK
Civil P’port No: KM 474409	Place of issue: ODESSA	Date of issue: 20.06.2007 20.
USA visa No:	Issued:	Valid:	Place of issue:

Medical information

Medical examination	Issued:16.02.2015	Valid:16.02.2016	Weight, kg :75	Height, cm: 185
Drug & alcohol test	Issued:16.02.2015	Valid:16.02.2016	Eyes: brown	Hair: dark brown
Yellow fever	Issued: 01.06.2015	Valid:01.06.2025	Overall size:	Safety shoes: 43

Name of marine school attended	Address of school	From	To	Degree of diploma
Odessa National Marine University Odessa National Marine Academy	34 Mechnikova str. 8 Didrikhson str.			Hicher(specialist)

National License

Certificate of competency hold	Number	Issued	Valid	Place of issue
Диплом	11010/2015/08	12.03.2015		Odessa
Endorsement

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)	1625/2015-A	10.02.2015	10.02.2020	Odessa
2.03	Advanced fire fighting (A-VI/3)	5158/2015-A	01.04.2015	01.04.2020	Odessa
1.23	Prof. in survival craft (A-VI/2 p.1-4)	6335/2015-A	26.03.2015	26.03.2020	Odessa
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)	182/2015-A	24.02.2015	24.02.2020	Odessa
	Ship security officer
	Ship handling arrangements
	Свид-ство о повышении квалификации

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
Grigoleti				fishing	70 t			Deck cadet	09.12.2014	14.02.2015

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