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Please note that due to legal requirements boarding is only possible after we are in possession of photo copies of all listed
documents and certificates - in urgent cases you may therefore have to send them email (color scans in.jpg format –
max. 600 pixel wide and max. 900 pixel high) or by fax or courier. Passport photos may arrive later (by mail).
| Family Name | СHUBANOV | First Name(s) | ROMAN | Rank | 2-3ENG. | ||
| A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES | |||||||
| Document Name (Desciption) | Document Number | Country | Issue Place | Issue Date | Exp. Date | ||
| Passport (загранпаспорт) | Russia | Murmansk | 09.12.2011 | 09.12.2021 | |||
| Seaman's Book (паспорт моряка) | Russia | Murmansk | 15.02.2012 | 14.02.2017 | |||
| Seaman's Book (flag state) | |||||||
| Seaman's Book (flag state) | |||||||
| Visa - United States (type C1/D) | |||||||
| Visa - Others (Work/Resid. Permits) | |||||||
| Medical Examination Report | Russia | Murmansk | 30.03.2015 | 30.03.2016 | |||
| Drug & Alcohol Test | |||||||
| Vaccination against Yellow Fever | |||||||
| Vaccination against Cholera | |||||||
| Passport Photos | please mail 6 for deck officers & 4 for other ranks (required for flag states) | ||||||
| B. CERTIFICATES OF COMPETENCY & ENDORSEMENTS, COURSE CERTIFICATES | |||||||
| - deck & engine certificates & endor- sements (officers / ratings) - electrical & reefer certificates - cook & steward certificates | - radio certificates & endorsements - safety training (surv., fire, medical) - tanker courses (oil, chem., gas) - passenger vsl, roro, hazmat courses | - nav., deck, technical & management courses (radar/ARPA, ISM, Marpol, simulators, computer, welding etc.) - any flag state certificates | |||||
| Document Name (Desciption) | Document Number | Country | Issue Place | Issue Date | Exp. Date | ||
| Certificate of competency - | 2-Eng 2035700047 | Russia | Astrakhan | 10.09.2014 | 10.09.2016 | ||
| GMDSS GENERAL/OPERATIONAL | |||||||
| ENDORSEMENT GMDSS | |||||||
| RADAR/ARPA | |||||||
| ADVANCED FIRE FITING | Russia | Murmansk | 26.05.2011 | 26.05.2016 | |||
| PROFICENCY IN SURVAVAL CRAFT AND RESCUE BOAT | Russia | Murmansk | 24.05.2011 | 24.05.2016 | |||
| PERSONAL SURVIVAL | Russia | Murmansk | 20.05.2011 | 20.05.2016 | |||
| MEDICAL FIST/MEDICAL CARE | Russia | Murmansk | 01.06.2011 | 01.06.2016 | |||
| Training of seafarers with designated security duties | Russia | Astrakhan | 27.08.2014 | 27.08.2019 | |||
| CAYMAN ISLANDS ENDORSEMENT | |||||||
| ISM TRAINING | |||||||
| INTERNAL SMS AUDITOR | |||||||
| Date: 26.03.2015 | Signature: CHUBANOV | ||||||
Attn.: Marlow Navigation - Crew Department (Administration Group)
SEAFARER'S APPLICATION FORM - Page 3 of 3 - SEA SERVICE (LAST 10 YEARS)
Please indicate your sea service in the last 10 years as exactly as possible - required are the actual sign-on and sign-off dates according to the service certificates resp. seaman's book entries. To speed up processing kindly indicate phone and/or fax numbers of your previous employers. Ship sizes are to be indicated in gross tons, total engine output in kilo Watt (1 kW = 1.34 bhp) to go along with STCW limitations. Please attach evidence for the listed sea service (copies of seaman's book entries, service certificates etc.). The information provided may be passed on to our clients and to flag state administrations to allow for verification of rank experience. Please use the European date format (DD.MM.YY).
| Family Name: | CHUBANOV | First Name(s): | ROMAN | Date of Birth: | 09.10.1974 | ||||||||
| Vessel's Name | Flag | DW | kW | Ship Type | Rank | S/On Date | S/Off Date | Employer (company to contact for reference) | |||||
| NEFTEGAZ-55 | Russia | ZULCER 5995 KW | AHTS | 2-Eng | 27.09.2014 | 27.01.2015 | AMNGR | ||||||
| NEFTEGAZ-55 | Russia | ZULCER 5995 KW | AHTS | 3-Eng | 02.10.2013 | 10.02.2014 | AMNGR | ||||||
| NEFTEGAZ-55 | Russia | ZULCER 5995 KW | AHTS | 3-Eng | 30.11.2012 | 05.04.2013 | AMNGR | ||||||
| NEFTEGAZ-55 | Russia | ZULCER 5995 KW | AHTS | 3-Eng | 29.03.2012 | 02.07.2012 | AMNGR | ||||||
| KAPITAN VODENKO | Cyprus | MAN 11700KW | CENERAL CARGO | 3-Eng | 20.04.2011 | 22.09.2011 | "NB SHIPPING", LTD Cyprus Limassol | ||||||
| KAPITAN VODENKO | Cyprus | MAN 11700KW | CENERAL CARGO | 3-Eng | 28.12.2009 | 20.05.2010 | "NB SHIPPING", LTD Cyprus Limassol | ||||||
| KAPITAN VAKUIA | Cyprus | MAN 11200KW | CENERAL CARGO | 4-Eng | 30.09.2008 | 25.03.2009 | "NB SHIPPING", LTD Cyprus Limassol | ||||||
| Vladimir Rusanov | Russia | Mak 6600 Kw | CENERAL CARGO | 4-Eng | 12.04.2007 | 19.10.2007 | MSCO | ||||||
| POMORYE | Russia | MAN&BW 9480Kw | CENERAL CARGO | Motormen | 11.05.2006 | 19.02.2007 | MSCO | ||||||
| Date: 26.03.2015 | Signature: Chubanov | ||||||||||||
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