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APPLICATION FORM
In accordance with seaman s book in English Language |
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4. Surname | Koloskin | 5 .First name | Mykola | |
6 .Father name | Mykolayovich | 7 .Citizenship | Ukraine |
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8 .Date of birth | 23.09.1990 | 9 .Place of birth | Izmail |
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10 .Nationality | Ukrainian | 11 .Religion | Orthodoxy |
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12 .Home address | (Apartment, building, street, city, region, postal zone, country) 100, Kirova str., Kisliza village, Odessa region, Ukraine | 13 .Personal details (in Ukrainian units of) | ||
Hair | ||||
14. Phone/Mobile | Mbl.: +38 068 840 18 95/+38 095 516 21 02 | Eyes | ||
Height | ||||
15. Marital status | Married: Divorced: Single (Never married): Separated: Widowed: | Weight | ||
16. Children`s | Under 18 Yrs: - Dates of birth: | Headdress | ||
17 .Next of kin /Relation | Koloskina O.A. (relation, surname, father name) | Shoes size | ||
Overall size | ||||
18. Next of kin Address | 106, Leninskii avenue, 154 ap., Donetsk city, Ukraine. (apartment, building, street, city, region, postal zone, country) | 19. Distinduish marks | ||
NONE | ||||
20. Agency remarks |
Expected Wage |
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1 .Position | OS | 2 .Filled | 30.10.14 | 3 .Ready | 30.10.14 |
Ukrainian Educational diploma | ||||
Speciality | Educational Institute name (22.) and address (23.) | Diploma | Issued | Higher |
21. Second Class Seaman | 22. Training and Certifying Center, Ukrainian Danube Shipping Company 23. | 24. 090153
| 25.11.09.14
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Ukrainian Certificate of Competency and Endorsement | ||||
Speciality | Given by | Number | Issued | Valid |
26. Second Class Seaman | 27. port of Izmail, Harbour Master
| 28 11694/2014/01
| 29. 07.10.2014 | 30. |
31. Endorsement | 32. port of Izmail, Harbour Master
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English (degree/mark) | FLUENT |
| GOOD | FAIR | BASIC | |||
Other languages | 36. |
Ukrainian Passports and Medical documents | ||||
Document | 37. Number | 38. Issued | 39. Valid | 40. Issued Place |
Travel passport | ET 023898 | 17.06.2011 | 17.06.2021 | |
Seaman’s book | AB 535707 | 04.11.2014 | 04.11.2019 | Izmail |
Medical Fitness |
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Drug and alcohol |
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Yellow fever |
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Previous sea service | |||||||||
42.Name of vessel | 43.Flag | 44.Type | 45.Dwt | 46.Engine | 47.HP | 48.Owner | 49.Rank | 50.From | 51.Till |
Capitan Glushko | UA | tug |
| 2*756 | Ukrainian Danube Shipping Company | cadet | 01.05.14 | 07.07.14 | |
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52. Remarks: |
Ukrainian STCW- 78/95 and other certificates | ||||
Document |
53.Number |
54.Issued |
55.Valid |
56.Issued Place |
Basic Safety Training | 20777/MPS | 29.08.14 | 29.08.19 | Izmail |
Proficiency in Survival Craft | 20778/MPS | 03.11.14 | 03.11.19 | Izmail |
Proficiency in Fast Rescue Boats | 20778/MPS | 03.11.14 | 03.11.19 | Izmail |
Advanced Fire Fighting |
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Medical First Aid |
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Medical Care |
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GMDSS Certificate |
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GMDSS Endorsement |
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Radar Observation & Plotting |
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Automatic Radar Plotting Aids |
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Dangerous & Hazardous Cargoes |
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Hazardous materials |
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Security-Related | 20014/MPS | 26.08.14 | 26.08.19 | Izmail |
Designated Security | 26269/MPS | 27.08.14 | 27.08.19 | Izmail |
Isolating Breathing Apparatus |
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RO-RO Passenger Ship |
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RO-RO Ship |
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Tanker Familiarization |
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Oil Tanker Specialized Training |
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Gas Tanker Specialized Training |
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Chem. Tanker Specialized Specialized |
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Grude oil washing |
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Inert Gas Systems |
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Ship Handling Arrangements |
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Bridge Resources Management |
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Vapor Recovery Systems |
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Refresher & Updating |
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Maintenance of electrical and electronic engineering |
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ISM code |
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Flag state passports, Iicenses visas and other documents | ||||
Document name / Details | Given by | Number | Issued | Valid |
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| 63. |
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Reference | |
Extra Master |
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Extra Chief Engineer |
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Signature of Seaman_________________________ Operations manager_______________________
Дата добавления: 2015-11-04; просмотров: 16 | Нарушение авторских прав
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