Application form for employment

APPLICATION FORM FOR EMPLOYMENT ST. PETERSBURG

	Family Name: Urvantsev	Home Phone: Mob. Phone: [phone] Other Contact Phones: E-mail: [e-mail]
	First Name: Vladimir
	Middle name: Vladimirovich
	Date of Birth: 31/01/1959
	Place of Birth: Novosibirsk
	Nationality: RF Marital status: Married X Single No of Children:
	Home Address:
	Education: Secondary Higher X Education Body:
	Knowledge of English. Speak: Excel XGood Fair CES-test: __________% MARLINS-test: __________%
	Personal Info: Eyes: Grey Hair: Grey Height: 165 sм Weight: 90 kg Overall: 52 Shoes: 41
	CERTIFICATES	Grade	Number	Issue Date	Issue Place	Expiry Date
	Certificate of Competence	master		11.01.2007	Petropavlovsk-Kamchatskiy	09.06.2016
	Tanker Endorsement OIL	management	ТП№ 0137005	04.12.2014	Vanino	22.01.2019
	Tanker Endorsement CHEM	NO
	GMDSS	GOC		14.12.2006	Petropavlovsk-Kamchatskiy	20.09.2017
	Endorsement of GMDSS	master		14.12.2006	Petropavlovsk-Kamchatskiy	20.09.2017
	Radar Observ. Simulator			15.07.2011	Vladivostok	15.07.2016
	ARPA			15.07.2011	Vladivostok	15.07.2016
	Basic safety training	-----		17.06.2011	Vladivostok	17.06.2016
	Advanced Fire-Fighting	-----		20.06.2011	Vladivostok	20.06.2016
	Survival craft & rescue boat	-----		15.06.2011	Vladivostok	15.06.2016
	First Aid at Sea	-----		09.06.2011	Vladivostok	09.06.2016
	Medical Care	-----		21.102014	Saint-Petersburg	21.10.2015
	Carriage of D-s &Has-s sub-s	-----
	Carriage of D-s &Has-s sub-s(49)	-----
	SSO Certificate			13.09.2013	Saint-Petersburg	13.09.2018
	Security awareness
	Designated security duties			06.09.2013	Saint-Petersburg	06.09.2018
	ECDIS			07.03.2014	Vladivostok	06.03.2019
	Bridge Team Management
DOCUMENTS	Number/Type	Issue Date	Issue Place	Expiry Date
Seaman's Passp / ID	RUS 0243239	24.02.2014	Petropavlovsk-Kamchatskiy	23.02.2019
Seaman's Book	NO
Travel Passport	64 #4846127	30.06.2011	Petropavlovsk-Kamchatskiy	30.06.2016
Health Certificate	-----	21.10.2014	Saint-Petersburg	21.10.2015
Yellow Fever	-----	10.10.2011	Saint-Petersburg	10.10.2021
Drug and Alcohol	-----
Visa USA	F1086912	26.09.2012	Vladivostok	24.09.2015
Visa Schengen

Applicant’s Signature ____ В. Урванцев ____________________

Sea Service for last 10 Years

Name of Vessel	IMO	Vessel Type	DWT	Year of Built	Main Engine	Rank	Sign On Date	Sign Off Date	Reason for leaving	Owner / Crewing Co. Crewing Contact details (Name, phone number)
Model	Power BHP/KW
Бухта Океанская		Рыб. Доб.					Капитан	04,2005	11,2008	Собств. Жел.	ООО «Антей»
Октопус		ТК					Капитан	09,2009	11,2009	Собств. Жел	ООО «Октопус - Кап»
Антей		Рыб. Доб.					Ст. Пом.	03,2010	12,2010	Оконч. Контр	ООО «Камлайн»
Валерий Маслаков		Рыб. Доб.					Ст. Пом.	12,2010	06,2011	Оконч. Контр	ЗАО «Атолл-Запад»
Прометей		Рыб. Доб.					Капитан	12,2011	01,2013	Оконч. Контр	ООО «Камчатпромфлот»
Залив Васильева		Рыб. Доб.					Капитан	01,2013	07,2013	Оконч. Контр	ООО «Подолье»
Ясный		Рыб. Доб.					Капитан	09,2013	12,2013	Оконч. Контр	ЗАО «Курильский Рыбак»

I certify that the information contained in this application is true and complete. I understand that any false information, statement, omission or misrepresentation on this application form constitutes sufficient cause to refuse my employment or to dismiss me at a later stage, if employed with Interorient, irrespective of the timing the firm discovers the true facts.

The information you provide on this application form will be used to the extent necessary within the company and its Branch offices and may be made available to shipowner clients for evaluation purposes. We do not sell, trade, exchange or otherwise make available your data to any other third parties with the exception of limited data within investigation reports as may be required by proper authorities. An individual may review the information we hold about him/her on their request.

Applicant’s Signature ______ В. Урванцев _____ Date __ 02.07.2015 ____

Дата добавления: 2015-11-04