Personal data / application form

PERSONAL DATA / APPLICATION FORM

Position applied for _3^rd engineer Date of Readiness: now

Surname: Chepalis	Name: Ivan Father's name: Vasyliy
Date of birth: 01/04/1989	Place of birth: Izmail	Nationality: Ukraine	Marital status: Single
Address: Odessa, Malovskogo str. 10	Mobile: [phone]	E-mail: [e-mail]
English Language (Excellent, Good, Satisfactory): Excellent
Next of kin and relationship: Chepalis Nadezhda, mother	Children (name & DOB): none
Next of kin’s address: Izmail, Pavlova str., 14	Next of kin tel: [phone]
Inter. P’port No: EE828201	Issued: 26/12/2008	Valid: 26/12/2018	Place of issue: Odessa
Seaman's book No: AB493184	Issued: 27/03/2012	Valid:27/03/17	Place of issue: PORT IZMAIL
USA visa No:	Issued:	Valid:	Place of issue:

SEA GOING EXPERIENCE FOR THE LAST 5 YEARS

(MOST RECENT VESSEL LAST)

Name of vessel	Year of built	Company Owner/ Ship Manager	Flag	Type of vessel	DWT	Type of main engine	BHP	Rank	From Day,mont,year	To Day,month,year
Fairmount Expedition		Fairmount Marine BV	Netherlands	AHTS		4 x Wartsila 6L32		Wiper	06/06/2009	17/12/2009
Surinam River		Universal Marine BV	Netherlands	Container ship		MAN B&W 7L58/64		3^rd eng	31/05/2011	02/10/2011
Orinoco River		Universal Marine BV	Netherlands	Container ship		MAN B&W 7L58/64		3^rd eng	02/04/2012	18/09/2012

STCW Certificates	Number	Issued	Valid	Place of issue	STCW Certificates	Number	Issued	Valid	Place of issue
Certificate of competency	00623/2010/01	29/07/2010		Port Izmail	GMDSS Endorsement
Endorsement	00623/2010/01	29/07/2010	22/06/2015	Port Izmail	Radar observer
Personal safety	1918/2010	04/06/2010	04/06/2015	OMTC	ARPA
Advanced fire fighting	1073/2010	04/06/2010	04/06/2015	OMTC	AIS course
Prof. in survival craft	1350/2010	04/06/2010	04/06/2015	OMTC	BTM course
Medical first aid	0916/2010	04/06/2010	04/06/2015	OMTC	Security officer (ISPS)
Medical care					Safety officer (ISM)
Hazardous cargoes	0878/2010	04/06/2010	04/06/2015	OMTC
Ro-ro pass.ship’s
Tanker Familiarization	0650/2008	22/12/2008	22/12/2013	OMTC

Medical examination	Issued: 16/05/2011	Valid: 16/05/2012	Weight, kg: 100	Height:190
Drug & alcohol test	Issued: 16/05/2011	Valid: 16/05/2012	Eyes: Dark	Hair: Dark
Yellow fever	Issued: 05/02/2009	Valid: 05/02/2019	Overall size: 58	Safety shoes: 45

Another States Seamen’s Books	Document No	Issued	Valid		Another States Certificates of competency	Rank	Document No	Issued	Valid
Netherlands		15/04/2009	15/04/2019		Netherlands	3^rd engineer	00623/2010/01	27/05/2011	22/06/2015
Cyprus	cy191465	24/04/2012	24/04/2022		Cyprus	3^rd engineer	00623/2010/01	24/04/2012	22/12/2013

Signature______ ____________ Date ______13/11/2012 _______­

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Дата добавления: 2015-11-04