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S E A M A N ' s A P P L I C A T I O N F O R M
A. SEAMAN'S PERSONAL DETAILS
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POSITION TO APPLY FOR | 3RD OFFICER | CERTIFIED FOR |
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NAME / SURNAME | IGOR KICHUK | ||||||
FATHER'S NAME | VLADYMIR | MOTHER'S NAME | NATALIA | ||||
D.O.B./P.O.B. | 02.07.1982 ODESSA | NATIONALITY | UKRANIAN | ||||
Height (in cm): | Weight (Kg):68 | Shoes size:41-42 | Parka size:48-50 | ||||
ADDRESS | UKRAINE, ODESSA, BOGATSKOGO STR., 55, APP. 28 | ||||||
MOBILE No.: PHONE No.: | (+380) 063 283 17 66 (+380 482)42-36-90 | SKYPE ADDRESS: | igor.kichuk | ||||
MARITAL STATUS | MARRIED YES X NO q | CHILDREN YES X NO q | HOW MANY UNDER 18 YRS OLD..2.. | ||||
NEXT OF KIN | KICHUK MARINA | RELATION | WIFE | ||||
SEAMAN'S PASSP NO. | AB 536356 | ISS / VALID DATE | 16.09.14 / 16.09.19 | ||||
CIVIL PASSP NO. | KK 106310 | ISS / VALID DATE | 13.10.1998 | ||||
AUSTRALIAN MCV No. | ISS / VALID DATE | ||||||
GRADUATED FROM | ODESSA NATIONAL MARITIME ACADEMY 1999 - 2005 | ||||||
ENGLISH ABILITY | FLUENT q | VERY GOOD q | GOOD X | FAIR q | |||
B. NATIONAL CERTIFICATION | |||
CERTIFICATE | NUMBER | ISSUING - VALIDATION DATE | ISSUING PLACE |
CERTIFICATE OF COMPETENCY | 12252/2014/08 | 09.09.2014 | ODESSA |
ENDORSEMENT OF CERTIFICATE | 12252/2014/08 | 09.09.2014 - 04.09.2019 | ODESSA |
GMDSS (DECK OFF.) | 11886/2014/08 | 20.08.2014 | ODESSA |
ENDORSEMENT OF GMDSS | 11886/2014/08 | 20.08.2014 - 18.08.2019 | ODESSA |
SHIP SECURITY OFFICER | 06.08.2014 - 06.08.2019 | ODESSA | |
DESIGNATED SECURITY DUTIES | 0294/2014 | 06.08.2014 - 06.08.2019 | ODESSA |
BASIC SAFETY | 06.08.2014 - 06.08.2019 | ODESSA | |
PROFICIENCY IN SURV CRAFT | 06.08.2014 - 06.08.2019 | ODESSA | |
MEDICAL FIRST AID | 06.08.2014 - 06.08.2019 | ODESSA | |
ADVANCED MEDICAL CARE |
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ADVANCED FIRE FIGHTING | 06.08.2014 - 06.08.2019 | ODESSA | |
RADAR (DECK OFF.) | 08.08.2014 - 08.08.2019 | ODESSA | |
ARPA (DECK OFF.) | 08.08.2014 - 08.08.2019 | ODESSA | |
ECDIS | 06.08.2014 - 06.08.2019 |
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BRIDGE TEAM MANAGEMENT | 06.08.2014 - 06.08.2019 |
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DYNAMIC POSITIONING OPERATOR | 11/424/2014 | 14.11.2014 | ODESSA |
C.O.W. / IGS |
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LAST MEDICAL | 05.08.2014 - 05.08.2015 | ODESSA | |
VACCINATIONS | YELLOW FEVER: DOI....22.09.2014.... DOE.... 22. 09. 2024 …… CHOLERA: DOI …………………… DOE …………………… |
C. FLAG CERTIFICATION | |||||
FLAG | TYPE / No. (S.BOOK/ENDORS/STICKER) | RANK | ISSUED | VALID | Based on NATIONAL ENDORSEMENT NUMBER |
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D. PREVIOUS SEA SERVICE | |||||||
VESSEL | FLAG | TYPE/DWT | ENG/HP | RANK | S/ON | S/OFF | COMPANY |
BLUE PRINCESS | LIBERIA | B/C / 37,049 | SULZER/9,500 | 3RD OFF | 10.10.06 | 10.05.07 | V'SHIPS |
BLUE PRINCESS | LIBERIA | TN-C / 37,049 | SULZER/9,500 | 3RD OFF | 26.08.05 | 15.06.06 | V'SHIPS |
EUROCARRIER | MALTA | R/R / 7,662 | SEMT/8,190 | 3RD OFF | 15.12.03 | 15.06.04 | SAFINA |
GEROI PLEVNY | UKRAINE | VFERRY/19,019 | B&W / 17,600 | CDT-DECK | 13.06.01 | 29.09.01 | UKRFERRY |
GEROI SHIPKI | UKRAINE | VFERRY/20,000 | B&W / 17,600 | CDT-DECK | 19.05.00 | 24.08.00 | UKRFERRY |
Version: 1/13 Seaman’s Signature……………………………
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