Father's name: Oleksandrovich

APPLICATION FORM

POSITION:____________________ Engine Cadet________________________________________________

Surname: Nikita

Name: Kolosov

Father's name: Oleksandrovich

Date of birth: 22/08/1994

Place of birth: Odessa

Nationality: Ukrainian

Marital status: Single

Address (permanent): Greek str №9, Odessa Ukraine

Tel (including city cod):

Mobil:

English Language- 5 4 3 2 1 - 3

E-mail: [e-mail]

Marlins test:

CES 4.1:

Minimum required salary in USD:

Next of kin and relationship:

Next of kin’s address: Next of kin tel:

Next of kin’s phone:

Travel Passport: EP535665

Issued: 22/11/12

Valid: 22/11/22

Place of issue: Ukraine

Seaman's book: AB505343

Issued: 26/11/12

Valid: 26/11/17

Place of issue: Ukraine

Civil Passport: KM682615

Issued: 03/11/10

Place of issue: Ukraine

USA Visa: -----

Education:

Year:

Grade:

Working grade:

SEA GOING EXPERIENCE FOR THE LAST 5 YEARS

(MOST RECENT VESSEL LAST)

Name of vessel

IMO number

Year of built

Company Owner/ Ship Manager

Flag

Type of vessel

DWT

Type of main engine

BHP

Rank

From dd, mm, yyyy

To dd, mm, yyyy

Atlantika

Delfik Grace Shipping Ltd

Malta

bulker

28693 r.t.

B&W

Engine Cadet

15 October 2013

22 April 2014

СERTIFICATES

STCW Certificates	Number	Issued	Valid	Place of issue	STCW Certificates	Number	Issued	Valid	Place of issue
Certificate of competency Capacity _________________					Tanker familiarization
Endorsement					Oil advanced (V/1)
Basic Safety Training (VI/1)	0924/2014	25/04/14	25/04/19	Ukraine	Chemical advanced (V/1)
Proficiency in survival craft & rescue boats (VI/2)	0670/2014	28/04/14	28/04/19	Ukraine	Gas advanced (V/1)
Advanced fire fighting (VI/3)	0597/2014	29/04/14	29/04/19	Ukraine	IGS (Inert gas system)
Medical First Aid (VI/4)	0520/2014	29/04/14	29/04/19	Ukraine	COW (Crude oil washing:)
Medical Care (VI/4)					Bridge Team Management
Dangerous and Hazardous Cargoes (B-V/b,B-V/c)					Ship’s Handling (B-V/A)		23/05/14	23/05/2019	Ukraine
Ship Security Officer (VI/5)					Radar Navigation (Radar & ARPA)
Ship Safety Officer (ISM Code)					ECDIS
GMDSS					Security awareness training for all seafarers (A-VI/6-1)		10/10/14	10/10/19	Ukraine
GMDSS endorsement					Designated security duties of shipboard personnel (A-VI/6-2)		10/10/14	10/10/19	Ukraine

С автоматизированной обработкой моих персональных данных указанных в анкете, их передачей (включая трансзаграничную) и хранением в целях трудоустройства согласен. Подпись________

Дата добавления: 2015-08-27